Ministerial Inquiry into Allergies to Peanuts, Nuts and Sesame Seeds in Commercial Air Travel - Report of the Inquiry Officer

Executive summary

Introduction and background

The Canadian Transportation Agency (Agency) is an independent quasi-judicial tribunal of the Government of Canada. Part V of the Agency's enabling statute, the Canada Transportation Act, S.C., 1996, c. 10 (CTA), contains accessible transportation provisions which confer on the Agency the responsibility to eliminate undue obstacles to the mobility of persons with disabilities within the federal transportation network. The importance attached by Parliament to this responsibility is reflected both in Canada's national transportation policy contained in section 5 of the CTA and in the legislation's substantive provisions that mandate the elimination of undue obstacles in the network through regulation and complaint adjudication on a wide range of matters.

In response to several complaints against Air Canada and Jazz Aviation LP (Jazz) regarding passenger allergies to peanuts and nuts, the Agency issued Decision No. 228-AT-A-2011 (Allergy Decision). Subsequently, in response to a complaint against Air Canada and Jazz regarding passenger allergies to sesame seeds, the Agency issued Decision No. 134-AT-A-2013.

In February 2015, the former Minister of Transport, Lisa Raitt, P.C., M.P., directed the Agency, pursuant to section 49 of the CTA, to conduct an inquiry into the issue of passenger allergies to peanuts, nuts and sesame seeds onboard aircraft with 30 or more seats on domestic and international flights operated by Canadian air carriers, and on international flights to and from Canada operated by foreign air carriers (Ministerial Inquiry).

The scope of the Ministerial Inquiry included an examination of the effectiveness of current risk mitigation measures, as outlined in the Allergy Decision. The Allergy Decision required the following from Air Canada and Jazz:

when at least 48-hour advance notice is provided to it by persons with disabilities due to their allergy to peanuts or nuts, Air Canada will create a buffer zone as follows for the passenger with a disability due to allergy to peanuts or nuts:
1. for international wide-body aircraft executive class seating, the buffer zone will consist of the pod-seat occupied by the person with a disability due to their allergy to peanuts or nuts;
2. for North American business class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated;
3. for economy class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated, and the banks of seats directly in front of and behind the person. In areas where a bulkhead is either directly in front of or behind the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated, the buffer zone will consist of the bulkhead, together with the bank of seats in which the person is sitting and the bank of seats directly in front of or behind the person (depending on the location of the bulkhead).
to only serve within the buffer zone snacks and meals which do not contain peanuts or nuts as visible or known components, but which may contain traces of peanuts or nuts as a result of cross-contamination.
to provide a briefing to passengers within the buffer zone that they must not eat peanuts or nuts, or foods which contain peanuts or nuts, and will only be served snacks and meals which do not contain peanuts or nuts.
Air Canada personnel are to address situations where a passenger refuses to comply with this requirement by moving the non-obliging passenger or, if necessary due to that passenger's refusal to move, moving the person with the disability due to their allergy to peanuts or nuts to a seat where the buffer zone can be established.

This report presents the findings of the Ministerial Inquiry.

Process

Following the direction from the Minister, the Agency, pursuant to subsection 38(1) of theCTA, appointed Mary-Jane Gravelle, Director of the Centre of Expertise for Accessible Transportation, as Inquiry Officer. The Inquiry Officer sought independent expertise on how passengers may be affected when peanut, nut and sesame seed allergens are introduced to them via inhalational, ingestion and topical (dermal) exposure while on board an aircraft, as well as how allergy particles move throughout an aircraft environment. Two expert reports were obtained: one concerning allergies to peanuts, nuts, and sesame seeds in the aircraft environment, and another concerning exposure to these allergens in the context of air circulation and filtration systems in aircraft cabins. The first report - In Flight Allergic Reactions to Peanut, Tree Nut and Sesame Seeds: A Risk Assessment and Management Strategies – was authored by Dr. Matthew Greenhawt, MD, MBA, MSc, an allergist and immunologist. The second report - Potential for Human Exposure to Peanut, Tree Nut and Sesame-Seed Based Allergens on in-Flight Commercial Aircraft Cabins – was authored by a National Research Council of Canada multi-disciplinary group with expertise in aerospace engineering, indoor air quality, ventilation, environmental health, exposure science, and biology.

Additionally, the Inquiry Officer conducted two rounds of consultations to gather information from air carriers that operate aircraft with 30 or more seats and from allergy associations. In the first round of consultations, air carriers were asked to provide information on their policies to accommodate passengers with allergies to peanuts, nuts and sesame seeds, including a description of the policy; statistics regarding the provision of accommodation to persons with these allergies; details on High Efficiency Particulate Arrestor (HEPA) filters on board their aircraft; a description of any difficulties encountered during the provision of accommodation measures; and ideas on best practices.

In the second round of consultations, air carriers and allergy associations were asked to comment on the expert reports and provide evidence-based opinions on a variety of questions related to risk mitigation measures and accommodation.

In addition to the expert reports and consultations, the Inquiry Officer conducted research on allergy policies of Canadian and foreign air carriers, as well as whether foreign jurisdictions have any related guidelines or regulations. As of the writing of this report, the research indicates that the Canadian government is the only one that has formally addressed the issue of allergies to peanuts, nuts and sesame seeds in the context of air travel. A review of the policies of 37 air carriers located in different parts of the world revealed that, internationally, allergy policies vary significantly. Similar to Canadian air carriers, it does not appear that any international air carriers have adopted a ban on peanut and nut-based allergens.

Expert reports

The expert reports examined risks of anaphylaxis (a severe, potentially life-threatening, systemic allergic reaction) and asthma due to ingestion, inhalation and topical exposure to peanuts, nuts and sesame seeds. The reports conclude that exposure via ingestion remains the most likely route of exposure when considering the risk of anaphylaxis. There is little to no evidence that there is a risk of anaphylaxis due to inhalation of or dermal contact with peanut, nut or sesame seed allergens; rather, any risk of a serious allergic reaction that might exist would be as a result of accidental ingestion.

Although in recent years there has been an increase in the number of reported in-flight allergic reactions, there is an inherent difficulty in gathering useful data, possibly due to the passengers having the reaction recalling the incidents in a way that supports pre-existing views regarding such things as the risk of exposure and the potential danger associated with it; or, because of improperly trained in-flight staff who are unable to accurately assess the reported allergic reactions. With respect to current risk mitigation measures, Dr. Greenhawt's report strongly recommends a review of the buffer zone policy set out in the Allergy Decision, including its effectiveness, placement and configuration vis-à-vis other measures of accommodation, such as a thorough cleaning of the passenger's immediate seating area.

Both reports recommend that risk mitigation measures be adopted, such as training in-flight staff to recognize signs and symptoms of an allergic reaction, replacing onboard emergency epinephrine ampoules (which use a needle and syringe) with auto-injectors (e.g. EpiPen®), providing passengers time to clean their seating area of any allergens, and providing accurate, readily available information on air carrier allergy policies to passengers. Finally, both reports recommend that a national registry be developed in order to track in-flight incidents, with a view to better identifying and treating the risks of allergic reactions, anaphylaxis or otherwise.

Analysis and findings

The Inquiry Officer analyzed the information gathered during the inquiry in terms of the following two key issues:

The risk of anaphylaxis due to inhalation, dermal contact with and/or ingestion of peanut, nut and sesame seed allergens while on board aircraft with 30 or more passenger seats; and,
The effectiveness of current risk-mitigation measures, as outlined in the Allergy Decision.

With respect to exposure routes for the risk of anaphylaxis, the Inquiry Officer found that there is little to no evidence that there is a risk of anaphylaxis due to inhalation of or dermal contact with peanut, nut or sesame seed allergens while on board aircraft. Rather, any risk that might exist would be as a result of accidental ingestion. Moreover, the Inquiry Officer found that the risk of an inflight anaphylactic reaction due to accidental ingestion of peanuts, nuts or sesame seeds is limited but that, given the serious health implications of such a reaction, risk mitigation measures are nonetheless warranted.

With respect to the effectiveness of current risk-mitigation measures, as outlined in the Allergy Decision, the Inquiry Officer found that although there was no consensus on a set of measures to mitigate the risk of anaphylaxis due to exposure to peanut, nut and sesame seed allergens during air travel, the following mitigation measures would be the most effective:

a buffer zone, consisting of the row in which the allergic passenger sits or the pod-seat, as applicable;
an announcement to other passengers within the buffer zone that they must refrain from eating peanuts, nuts or sesame seeds or foods containing these;
not serving meals or snacks containing peanuts, nuts or sesame seeds in the buffer zone (recognizing that any food may contain trace amounts of the allergens);
advising passengers with allergies to peanuts, nuts and sesame seeds who provide advance notification of their allergies that they are expected to take the same precautions they take during their daily living, including carrying their allergy medication on their person; wiping down their seat area to remove any allergens; bringing their own food;
abatement, by allowing passengers to wipe down their seating areas;
having policies on air carrier websites to inform passengers on how to make arrangements for accommodation and what their responsibilities are; and,
training flight crews on signs and symptoms of an allergic reaction.

1. Introduction and background

The Canadian Transportation Agency (Agency) is an independent quasi-judicial tribunal of the Government of Canada. Part V of the Agency's enabling statute, the Canada Transportation Act, S.C., 1996, c. 10, as amended (CTA), contains accessible transportation provisions that confer on the Agency the responsibility to eliminate undue obstacles to the mobility of persons with disabilities within the federal transportation network. The importance attached by Parliament to this responsibility is reflected both in Canada's national transportation policy contained in section 5 of the CTA and in the legislation's substantive provisions that mandate the elimination of undue obstacles in the network through regulation and complaint adjudication on a wide range of matters.

Food allergies are increasingly common, affecting the lives of many Canadians.

The most serious of these are allergies to peanuts, nuts and sesame seeds, common ingredients in many foods. People who have these allergies, and especially parents of children who have them, have heightened concerns about inadvertent exposure to the allergens. These concerns extend to air travel given the practice of some air carriers to serve snacks and foods containing nuts, peanuts and sesame seeds as well as the increasingly common practice of passengers bringing on board their own food, which often contains these same ingredients.

Between 2011 and 2013, the Agency issued two decisions in response to complaints regarding Air Canada's policies concerning allergies to peanuts, nuts and sesame seeds. These decisions ordered corrective measures that required Air Canada to implement policies to provide accommodation to passengers with these allergies in order to mitigate the risk of serious in-flight reactions (see section 1.1 for more detail on the corrective measures).

In order to examine the issue on a systemic basis, in February 2015 the former Minister of Transport, Lisa Raitt, P.C, M.P., directed the Agency, pursuant to section 49 of the CTA, to conduct an inquiry into the issue of passenger allergies to peanuts, nuts and sesame seeds on board aircraft having 30 or more seats on domestic and international flights operated by Canadian air carriers, and on international flights to and from Canada operated by foreign air carriers (Ministerial Inquiry).

The scope of the Ministerial Inquiry included the risk of anaphylaxis due to adverse contact with and/or ingestion of these allergens while on board aircraft and an examination of the effectiveness of current risk mitigation measures, including those ordered by the Agency to be implemented pursuant to Decision No. 228-AT-A-2011 (Allergy Decision).

Following the direction from the Minister, the Agency, pursuant to subsection 38(1) of theCTA, appointed Mary-Jane Gravelle, Director of the Centre of Expertise for Accessible Transportation, as Inquiry Officer to conduct the Ministerial Inquiry and report her findings to the Agency. This report reflects the results of the Ministerial Inquiry.

The Inquiry Officer sought independent expertise on how passengers may be affected when peanut, nut and sesame seed allergens are introduced to them via inhalational and topical (dermal) exposure while on board an aircraft, as well as how allergy particles move throughout an aircraft environment.

Dr. Matthew Greenhawt, MD, MBA, MSc, an allergist and immunologist with extensive research experience in peanut and nut allergies in air travel, developed a report that provides an understanding of allergies and a discussion of: the risk of reaction to allergens, including anaphylaxis due to ingestion, inhalation and topical exposure in public venues; risk mitigation strategies with supporting evidence (including measures implemented as a result the Allergy Decision); and optimal treatment and procedures to managing an allergic reaction to food that might occur on board a commercial flight.

A multi-disciplinary group of researchers with expertise in aerospace engineering, indoor air quality, ventilation, environmental health, exposure science, and biology from the National Research Council Canada's aerospace division developed a report on the potential for exposure to nut, peanut and sesame seed allergens within aircraft cabins, including an understanding of how allergy particles move and interact throughout an aircraft. The report includes a detailed literature review on the science regarding the potential for human exposure to these allergens within the aircraft cabin.

Summaries of the expert reports can be found in section 3 of this report.

1.1 Decision No. 228-AT-A-2011 (Allergy Decision)

In the Allergy Decision^{Note 1}, the Agency addressed complaints filed by Sophia Huyer and Rhonda Nugent, on behalf of her daughter Melanie Nugent, regarding difficulties they experienced with respect to peanut and nut allergies while travelling with Air Canada. The order arising from the adjudication of these complaints was therefore limited to Air Canada.

In the Allergy Decision, the Agency determined that a buffer zone meets the needs of persons with disabilities due to their allergy to peanuts and/or nuts as the buffer zone would sufficiently reduce the potential for accidental ingestion. Specifically, the Agency determined that, when at least 48 hours advance notice is provided to Air Canada, it is required to create a buffer zone as follows:

For international wide-body aircraft executive class seating, the buffer zone will consist of the pod-seat occupied by the person with a disability due to their allergy to peanuts and/or nuts;
For North American business class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts and/or nuts is seated;
For economy class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts and/or nuts is seated, and the banks of seats directly in front of and behind the person.

The Agency also determined that Air Canada is to:

Only serve within the buffer zone snacks and meals which do not contain peanuts and/or nuts as a visible or known component, but which may contain traces of peanuts and/or nuts as a result of cross-contamination;
Provide a briefing to passengers within the buffer zone that they must not eat peanuts and/or nuts, or foods containing peanuts and/or nuts, and will only be served snacks and meals which do not contain peanuts and/or nuts;
Have Air Canada personnel address situations where a passenger refuses to comply with this requirement by moving the non-obliging passenger or, if necessary due to that passenger's refusal to move, moving the person with the disability due to their allergy to peanuts and/or nuts to a set where the buffer zone can be established.

The rationale for this Decision was based on information provided during the Agency's hearing of the allergy complaints, including expert evidence that suggested that the greatest risk of having a severe allergic reaction is from accidental ingestion, and that the creation of a buffer zone, in addition to air filtration and circulation systems in the aircraft, would also help to mitigate any risk of allergic reactions due to inhalational exposure. More specifically, ventilation systems for modern generation aircraft are designed so that the air exits the cabin at approximately the same row that it enters the cabin and the recirculated air is filtered through HEPA filters that are of similar quality as those used in critical wards in hospitals and industrial 'clean' rooms as they capture a minimum of 99.97 percent of contaminants at 0.3 microns in size, which is the most difficult particle size for a filter to capture.

With respect to the details of a buffer zone, Air Canada was asked to provide a submission on the recommended size of the buffer zone. Air Canada provided specifications and its rationale for those specifications for the buffer zones on its international wide body aircraft executive class, North American business class, and economy class seating, which the Agency accepted.

As part of its rationale for the size of the buffer zones in its various classes of service, Air Canada submitted that the aisle would provide a sufficient buffer between the bank of seats that the allergic passenger is seated in and the bank of seats across the aisle. The Agency accepted Air Canada's argument that there would be very little risk of a person seated in the bank of seats across a row touching the immediate vicinity of a passenger who is allergic to peanuts or nuts. In analyzing its findings with respect to the appropriate accommodation for persons with allergies to peanuts and nuts, the Agency also had to reflect a consideration of risk management as it would be impossible to create an entirely allergen-free environment in the aircraft cabin. The measures taken also assumed that persons with allergies to peanuts or nuts would, when travelling by air, take the precautions that they would normally take in their day-to-day lives, such as carrying wet wipes, hand sanitizers and Epi-pens (where prescribed by the person's physician).

In 2013, the Agency issued Decision No. 134-AT-A-2013, Rosenbaum v. Air Canada, (Rosenbaum Decision) regarding a complaint against Air Canada and Jazz Aviation LP, which concerned sesame seeds served in flight. In this particular case, the Agency found that the appropriate accommodation for persons with allergies to sesame seeds, as well as to all other foods except peanuts and nuts (which had been addressed in the Allergy Decision), was the reseating of these passengers, upon request and when possible having regard to safety considerations, in combination with precautions that persons with severe allergies would be expected to take in their daily lives, such as: bringing their own food, hand sanitizer(s), and disinfectant wipes to wipe down surrounding surfaces; wearing a mask; and carrying Epi-pens.

2. Environmental scan

2.1 Allergy policies for domestic air carriers

Although none of the Canadian air carriers operating aircraft with 30 or more seats ban peanuts, nuts and sesame seeds on their flights, most provide some sort of accommodation to passengers with allergies to peanuts, nuts and sesame seeds, depending on the level of advance notice provided to the carrier. Typically, these air carriers request at least 48 hours advance notice of a passenger's allergy.

The following provides an examination of current allergy policies for three of the larger domestic air carriers based on passenger volume and is based on the information available at the time of drafting of this report. A detailed comparison of allergy policies for domestic air carriers can be found in Appendix A.

Air Canada

Air Canada does not make public announcements alerting passengers that there is an allergic passenger on board; however, it will institute a buffer zone, provided that at least 48 hours advance notice is given (a reasonable effort will be made if the request is made if less notice is given).

In economy class, the buffer zone consists of the passenger’s row, in addition to the rows directly in front and behind the passenger’s row. Passengers seated in the buffer zone will be advised that there is a passenger with an allergy sitting in the zone and will be told that they are not permitted to consume peanut and/or nut products. Additionally, flight attendants will not offer any food items that contain peanuts or nuts to passengers seated in the buffer zone. In business class seating, the buffer zone is defined as the bank of seats in which the allergic passenger is seated and does not include additional rows. In international business class, the buffer zone consists of the "pod seat" occupied by the passenger with allergies.

WestJet

WestJet’s policy provides that, upon request or advance notification, a flight crew member will make an announcement to inform other passengers that a passenger has severe allergy to peanuts or nuts. Other passengers will be asked not to open or consume any peanuts, nuts or nut products during the flight. WestJet also does not serve nut products on its flights; however, it cannot guarantee that there are no traces of nuts and/or peanuts in the onboard snacks that are served.

Upon receiving a least 48 hours' advance notice from a passenger of their allergy, WestJet will provide a buffer zone consisting of two rows in front and two rows behind the passenger. Passengers sitting in the zone are advised that there is a passenger in the zone who has a severe allergy and are asked not to open or consume peanuts, nuts or nut products.

Passengers who inform a flight crew member of their peanut and/or nut allergy will be asked whether they have an epinephrine auto-injector on their person, and the location of the device; in addition, passengers will also be asked whether they are carrying any other allergy-related medications.

Porter Airlines

When at least 48 hours' advance notice has been provided by a passenger with an allergy, Porter will remove nut-based products from its in-flight service menu and assign seating in a buffer zone. Passengers seated in the zone are requested not to consume any nut products. Porter encourages passengers with nut allergies to take all necessary precautions and prepare for the possibility of exposure to nut allergens.

2.2 Requirements in international jurisdictions

Research undertaken as part of this inquiry did not indicate any foreign jurisdictions that impose obligations on air carriers regarding the transportation of passengers with allergies to peanuts, nuts or sesame seeds.

For example, in the United States of America, the issue has been left to the individual airlines to address, such that different carriers have instituted different policies, but no official regulation or policy from the Department of Transportation exists.

In the European Union, policy issues regarding the accommodation of passengers with allergies to peanuts, nuts and sesame seeds are not regulated by the state, but are left for aircraft operators to determine (similar to the United States of America).

The International Air Transport Association (IATA), a trade association representing over 260 airlines, has published a communiqué to allergen-sensitive passengers to help them minimize the risk of an allergic reaction on board an aircraft^{Note 2}. The document refers to an ICAO general standard requiring that an aircraft be equipped with "accessible and adequate medical supplies," which each national authority must meet. ICAO provides recommendations regarding the contents of medical kits that include antihistamine and epinephrine.

The IATA communiqué also describes an ICAO standard requiring airlines to establish and maintain a training program that ensures that cabin crew members are trained in first aid; however, the specific details of the training are left to the individual air carriers to determine. In addition, the communiqué includes the following recommendations for allergen-sensitive passengers:

Before travel:

Contact your physician and discuss the travel related risks involved; make sure you always carry, any have easily accessible, any medication prescribed for your allergy. You should never assume that the airline will carry the medication you need.
Make sure that you carry a prescription for any medication and an emergency plan signed by your doctor to avoid problems when passing through airport security.
When making a reservation, ask the airline how they deal with allergen-sensitive customers. Even if the airline does not serve the food to which you are allergic, it cannot guarantee an allergen-free environment.
Even though airlines carry out routine cleaning procedures of the aircraft, it is impossible to guarantee an allergen-free environment on board.
Allergen-sensitive minors should never travel unaccompanied.
If you purchase travel insurance, consider asking the insurance company if you are covered in case of anaphylaxis, or other severe allergic reactions.

Day of travel:

Arrive early at the airport and allow yourself plenty of time to re-confirm your requests regarding specific seating, early boarding, etc.
Consider mentioning to the passengers sitting close to you or your allergic child that you or your child has a severe allergy. Try to position a child with an allergy away from other passengers (a window seat for example or between yourself and your spouse or another one of your children).
Consider bringing your own sanitizing wipes if you wish to wipe down the armrests, meal trays and seat back areas of your seats.
Consider alerting the cabin crew in charge of the severe allergy so they can respond quickly and appropriately if a reaction occurs.
The safest option is to take your own food on board with you.

2.3 Allergy policies of international air carriers

A review of the policies of 37 air carriers located in different parts of the world revealed that, internationally, allergy policies vary significantly. Similar to Canadian air carriers, it does not appear that any international air carriers have adopted a ban on peanuts and nut-based allergens.

Of the 9 carriers based in North America (not including Canada) that have policies, 2 will offer "special meals" although these aren't guaranteed to be100 percent nut-free; 1 will create a buffer zone; 2 will make onboard announcements within a buffer zone or to passengers seated near the person with the allergy; and 3 will refrain from serving peanut/nut-containing meals or snacks.

Of the 10 air carriers based in Europe, 6 will offer "special meals" although these aren't guaranteed to be100 percent nut-free, 2 will refrain from serving peanut/nut-containing meals or snacks on board, and 1 will make onboard announcements.

Of the 8 air carriers based in Asia, 3 will offer "special meals" although these aren't guaranteed to be100 percent nut-free; 3will refrain from serving peanut/nut meals or snacks on board; and 1 will create a buffer zone.

Of the 3 carriers based in Australia/New Zealand, 1 carrier will offer "special" meals although these aren't guaranteed to be100 percent nut-free.

Of the carriers based either in South America or Africa, only 1 carrier will offer "special" meals although these aren't guaranteed to be 100 percent nut-free.

Appendix A offers a more detailed examination of international air carriers’ policies regarding allergy accommodations.

3. Expert reports

Expert reports are available by request ( email: info@otc-cta.gc.ca). If an accessible or French version is required, please ensure you indicate this preference in your email as there may be a delay.

3.1 In-Flight Allergic Reactions to Peanuts, Tree Nut and Seeds: Risk Assessment and Management Strategies (Dr. Matthew Greenhawt, M.D., MBA, MSc.)

Dr. Matthew Greenhawt was retained to produce a report on the risk of anaphylaxis due to adverse contact with, ingestion, and inhalation of peanut, nut and sesame seed allergens while on board an aircraft and the effectiveness of current risk-mitigation measures.

What follows is a summary of the findings in Dr. Greenhawt's report.

3.1.1 Findings

Section I: Immunoglobulin E (IgE) mediated food allergy, anaphylaxis, and asthma classification, types of adverse reactions to foods

Food allergies are a rapidly growing public health concern in Canada, the United States of America and other westernized nations. Generally speaking, a food allergy is defined as a loss of oral tolerance to food; essentially, the body becomes reactive to substances required to sustain human growth and development, which results in a specific immunologic reaction and subsequent symptoms. Food allergies can be confusing to diagnose and difficult to manage, causing a litany of issues for food allergy sufferers, including under-perception and over-perception of the disease, reduced quality of life, anxiety, parental frustration, social isolation and the potential for a life-threatening reaction.

There are two types of allergic reactions: immunologic and non-immunologic. Dr. Greenhawt notes the importance of distinguishing between the two types, as a layperson may describe and interpret any adverse reaction to a food as an allergy. This would be inaccurate as a food allergy is a very specific immune-mediated, adverse reaction to one or more protein allergens contained within a particular food item.

A host (the allergic individual) makes an antibody, called Immunoglobulin E (IgE) that has highly specific sites of recognition for certain protein sequences in the food allergen, called epitopes. An allergic reaction results from a specific epitope-to-IgE recognition and binding, which initiates a change in the membrane of the mast cell (a basophil cell that releases histamines during an inflammatory or allergic reaction) that subsequently releases chemicals that cause allergic symptoms. Dr. Greenhawt emphasizes that food sensitivity does not always result in a food allergy, as people may have food sensitization but are clinically tolerant of that food. Only a minority of sensitized individuals become food allergic.

Allergic and non-immunologic reaction mediators and pathways

A food-induced allergic reaction will occur when an allergen is exposed to a mucosal surface in a susceptible individual. Typical symptoms associated with an allergic reaction include itching, hives, swelling, flushing and fluid shifting from an increase in vascular permeability, cough/wheeze, decreased heart muscle contractility, and coronary artery spasm.

Exposure via localized cutaneous or skin-based contact can occur with allergen exposure to broken-down skin. Cutaneous exposure can also result in systemic sensitization in susceptible individuals.

Dr. Greenhawt notes that there is a limited amount of data suggesting that exposure to a food protein via inhalation can cause an allergic reaction and that, although this has been widely alleged to occur with peanut and tree nut allergens, this has not been substantiated.

There are also non-immunologic reactions that are often mistaken for allergic reactions. Examples include lactase deficiency, irritable bowel syndrome, headaches, joint pains and food intolerances, such as gluten sensitivity. Reactions to some of these conditions can be similar to allergic reaction-based events, such that it is easy for the person experiencing the condition to consider it to be an allergic reaction.

Clinical manifestations of food allergy

Symptoms of a food allergy usually present within several minutes to 2 hours of a known or suspected case of ingestion. In rare cases, symptoms may appear from 4 to 6 hours after ingestion. Delayed reactions (more than 12 hours after ingestion) are exceedingly rare, and those that are reported to occur more than 24 hours after exposure are almost never associated with IgE-mediated food allergy with the exception of eczema.

Allergic reactions can involve almost any organ system, but typically affect the skin, the upper or lower respiratory tract, the gastrointestinal tract, the cardiovascular system and the genitourinary [urinary and genital organs] tract.

Cutaneous allergic reactions may involve hives, swelling, flushing, itching and eczema. The most common initial symptom is hives, which can occur rapidly upon exposure to a food allergen.

Respiratory allergic symptoms may involve the upper respiratory tract, which can induce itching, throat clearing, and vocal/cough symptoms. Lower respiratory symptoms of an allergic reaction can include wheezing, dyspnea (difficult or laboured breathing) and coughing. Underlying conditions, such as asthma, can exacerbate an allergic reaction.

Although respiratory reactions to foods do not cause asthma, allergens can cause an acute asthma flare in susceptible individuals. Generally speaking, asthma involves airway obstruction, similar to stepping on a hose of flowing water causing spurting past the obstruction. The spurting will result in an audible wheeze and lung hyperinflation from air that becomes trapped proximal to the narrowing of the bronchial tubes. Some epidemiologic studies have indicated that up to a 1/3 of children with a food allergy may also have co-morbid asthma.

Cardiovascular allergic symptoms can include syncope (temporary loss of consciousness), hypertension, shock, and slow heart rate. Cardiovascular symptoms alone may be the only manifestation of a severe allergic reaction.

Common gastrointestinal allergic symptoms can include nausea, vomiting, diarrhea, or abdominal colic.

Oral allergy syndrome (OAS) is the most common food allergy manifestation, but on its own, is not a food allergy but rather a contact reaction mediated through cross-reactivity to plant-based foods in pollen-sensitive individuals. For example, OAS is very common in persons allergic to tree pollen (e.g. birch pollen) who consume peach, apple, plum and cherry; as well as persons allergic to weeds (e.g. ragweed) who consume melon, banana, potato, or avocado. Less than 5 percent of individuals with OAS experience gastrointestinal anaphylaxis.

Symptoms and severity of an allergic reaction

IgE-mediated reactions to foods can have various presentations and degrees of severity. Dr. Greenhawt cites a 2011 U.S. epidemiological study that notes that nearly 40 percent of participants reported that their food-allergic child had already experienced a severe reaction. Additional studies (some proxy-based, others report-based) indicate that severe reactions are more likely to occur in adolescents aged 14 to 17, youth that have multiple food allergies, and individuals with peanut, tree nut and sesame seed allergies.

Dr. Greenhawt notes that several factors could contribute to varying degrees of severity of the reaction, including: dose of exposure and the duration that the reaction is allowed to persist; other sources of systemic inflammation; and prior exposure to certain medications. Dr. Greenhawt also notes that patients with a past history of a severe reaction and patients with comorbidities, such as asthma, are generally felt to be at higher risk for future severe reactions.

Most allergy specialists are of the opinion that all persons with a food allergy are at high-risk for possible anaphylaxis. Criteria for anaphylaxis include solitary involvement of the cardiovascular system (e.g. syncope, hypotension), or two or more findings including skin/mucosal findings, respiratory symptoms, gastrointestinal symptoms, or cardiovascular findings. Up to 15 percent of all reactions may present with cardiovascular findings alone.

Onset of an anaphylaxis reaction can be quick after a susceptible individual is exposed to the allergen, such that prompt treatment with intramuscular epinephrine (also known as adrenalin) is necessary, with a recommended dose set at 1:1000 strength, 0.01mg/kg. Doses can be repeated every 5-15 minutes. Epinephrine will reverse any symptom of an allergic reaction but is most effective against low blood pressure and severe respiratory compromise. Other drugs, such as antihistamines, are effective in treating mild and mainly cutaneous symptoms, while corticosteroids are ideal for reducing the chance of a recurrence.

Fatalities from food-induced anaphylaxis are rare, but nevertheless a risk. Dr. Greenhawt notes that studies of food allergy fatalities have been limited, and fatality is likely an unrecognized event and difficult to definitively document. Two recent case studies of anaphylaxis fatalities from the US National Mortality Database noted a total of 164 food-related fatalities between 1999 and 2010.

Dr. Greenhawt notes that there has only been one reported in-flight fatality related to anaphylaxis, which occurred in the UK.

Prevalence/incidence of and specific risks associated with peanut, tree nut, and sesame seed allergies

Peanut, tree nut, and sesame seed allergies affect between 1-3 percent of individuals in Westernized nations. One self-reported Internet survey from 2010 indicated a 2 percent rate of peanut allergy, while in the United States of America, a three-part, self-reported phone-based survey noted the incidence of peanut and tree nut allergy has tripled in 10 years, from 0.4 percent to 1.4 percent. Recent Canadian data suggests the prevalence of peanut and tree nut allergies is at 1.3 percent and 1.4 percent of the general population, respectively. Sesame seed allergies affect approximately 0.2 percent of U.S. children and adults, 0.2 percent among native-born Canadians, and 0.8 percent among Australian 1-year olds. Dr. Greenhawt notes that there is some evidence to suggest that these numbers are on the rise.

Peanut, tree nut and sesame seed allergies share some commonalities, including that they are all plant-based allergens which share some structural similarities. The allergies also have potential cross-reactivity and cross-sensitization issues for the allergic individual. Nonetheless, they are all distinct food species; peanuts belong to the legume family, sesame is from the seed family, and most tree nuts are drupes (fruit with flesh surrounding a shell with a seed inside). Dr. Greenhawt notes that it is common clinical practice for many allergists to treat peanuts, tree nuts, and seeds (including sesame seed) as “equals” in terms of need for avoidance given confusion in their basic biologic understanding and visual recognition. Consequently, most allergists view avoidance of all potential threats as a benefit outweighing the risk of a sensitized individual consuming one of the items. However, Dr. Greenhawt points out that there is limited data suggesting that cross-reactivity actually manifests as an allergic reaction in the person who is sensitized but has never eaten one of the items. Dr. Greenhawt concludes that this may create the situation of unnecessary avoidance and requests for accommodation in public venues, given "the child is being managed as if they are clinically reactive despite never having ingested the item in question”.

Dr. Greenhawt notes that it is difficult to determine, with any precision, if there has been an increase in the incidence of allergic reactions to peanuts, nuts and sesame seeds. Although the term “epidemic” is routinely used to characterize the allergies – and few allergy specialists would argue against this statement given surging referrals and public interest/reports of peanut allergy – some circles have argued that discussion of peanut allergy as an epidemic is misleading, and that the arguments supporting this are circular and self-fulfilling. Measuring an increase in incidents is difficult given the paucity of studies with sufficient funds or the capacity to do so. Additionally, some studies use less reliable methods, such as proxy/self-reporting tools to collect data, which limits the ability to provide accurate information to explain any long-term trends in rates of food allergies. More specifically, there is a lack of provocation studies (a form of clinical trial whereby participants are exposed to either a substance or "thing" that is claimed to provoke a response) to verify potential increases in allergies to peanuts, nuts and sesame seeds, as they are costly and difficult to implement comparatively.

Section II: Public exposure to peanuts, tree nuts, and sesame seeds and the risk of reaction from inhalation or contact with allergen

Dr. Greenhawt notes that there is a general public concern, particularly from the food allergy community, that people allergic to peanuts, tree nuts and sesame seeds are susceptible to inhalational exposures or exposures to residues/oils smeared on common surfaces. Most of the concern relates to exposure to peanuts in the form of dust/shell fragments, peanut butter, and other products that might have come into contact with peanuts, while data on tree nuts and sesame seeds is not as well studied.

Inhalational exposure is commonly believed to be a highly susceptible route of exposure. However, despite a small quantity of experimental studies concluding that necessary precautions should be taken to avoid inhalational exposure, the data that does exist has consistently shown that: a) peanut dust does not aerosolize; b) peanut butter contains no protein in its vapours; and c) surfaces can be effectively cleaned of any allergic residue and, moreover, there is minimal risk of anything more than a local irritation reaction from casual skin contact with the allergen.

Dr. Greenhawt concludes that the risk of a reaction from public exposure is low, except in cases of ingestion. He cites a 2004 study designed to simulate a close proximity exposure to inhalation of peanut butter vapours and skin contact with peanut butter found on public sources to simulate the school environment. All 29 participants in the study had what was considered to be severe peanut allergies. The inhalation challenge portion of the study was carried out with 3 ounces of peanut butter (and soy butter for the placebo test), held at a distance of 12 inches from the participants' noses. Subjects were asked to breathe normally. The contact exposure portion of the study used 0.2 ml of peanut butter, directly smeared on the skin for 1 minute. None of the 29 study subjects demonstrated any systemic allergic reactions to inhalational exposure or to skin contact, and no respiratory symptoms developed. Dermal contact resulted in 3 patients developing localized erythema (redness of the skin or mucous membranes), which could be attributed to the acidic and irritant properties of butters applied topically and 5 patients had local pruritus (severe itching of the skin). The study concluded that casual environmental contact with or inhalation of peanut butter was highly unlikely to cause generalized reaction or any symptoms, debunking the idea that such exposures are a potential danger in a public venue.

Is there risk from environmental exposure on common surfaces or from inhalation exposure?

A similar study, also conducted in 2004, examined additional factors associated with possible casual environmental exposure to peanut allergens. The study looked at the effects of exposure to shelled peanut dust and peanut butter, as well as environmental allergen abatement (i.e., cleaning). The primary objective was to investigate whether 5 ml of smeared peanut butter could be successfully cleaned from tabletops, counters, desks, water fountains, and from one’s own hand. The study also attempted to intentionally create dust circulation to simulate inhalational exposure to potential peanut allergens.

The study’s authors found that standard household dish soap did not remove peanut allergen particles smeared on tabletops, but some commercially available cleaning products did. Handwashing results indicated that water or alcohol-gel-based hand sanitizers were ineffective at removing peanut allergen particles, but that certain wipes and liquid/bar soaps were successful.

Finally, the study noted that with respect to the circulation of dust particles, the authors were unable to detect any circulating airborne allergen particles on filters worn at the level of the patient’s neck after 15 bags of whole peanuts were shelled and then walked on in a small room, both with and without air ventilation.

Dr. Greenhawt notes that the data from the study demonstrates that peanut allergens can be effectively abated from both the skin and from common surfaces with a variety of available cleaning agents, and that there was an exceptionally low risk of airborne exposure given that the team could not detect any circulating allergen.

What is the risk of environmental distribution of peanut, the efficiency of cleaning to abate such levels; and the biologic relevance of such exposure?

A 2015 U.K. study, "Learning Early About Peanut" (LEAP), was designed to examine the effects of deliberate introduction of peanuts to children considered to be at risk for developing a peanut allergy at different ages; specifically, early exposure at 4-11 months of age versus deliberately delayed exposure at 5 years of age. The study examined peanut residue in 45 homes of LEAP subjects after participants were asked to not wash their bed sheets or vacuum the house for 5 days. Investigators collected peanut levels from dust samples and surface wipes were done in areas within the home in which peanuts were consumed. Peanut residue was found in several of the busiest areas of the house and surface wiping samples revealed traces of peanut residue on surfaces such as the dishwasher handle, tabletop, water tap, and crib rail. Dust samples had higher levels of peanut allergen than the wipe samples that Dr. Greenhawt considers would be expected given that the families were told not to vacuum their homes. Certain types of surfaces, such as laminate and wood, were smeared with peanut butter and then cleaned with a commercial cleaning product. These surfaces still held low but identifiable levels of peanut allergen; however, granite was revealed to have virtually untraceable levels of the allergen.

The same study explored two other routes of exposure: airborne allergen levels and levels in saliva after consuming peanuts. Airborne levels of peanut protein were measured using a sensitive airborne sampler, while a probe was used to measure peanut particles on various sources, such as a jar of peanut butter, a frying pan cooking peanut satay sauce, and a test subject. The study found that, at all times except when the peanut was being actively de-shelled, there was no detectable peanut above the lower limit of the "assay quantification" (i.e., detection limit), and even residual levels were not detected after de-shelling had ceased, although trace amounts were detected in saliva, 6 hours after consumption and mouth rinsing.

Dr. Greenhawt notes that, although there were trace amounts of peanut residue after cleaning surfaces, there is no proof that the residual levels detected were of any significance in terms of being able to trigger a reaction. Regarding aerosolization, Dr. Greenhawt points out that the study's authors found that peanut did not aerosolize other than temporarily being propelled by the act of de-shelling and then rapidly settled.

Dr. Greenhawt concludes that the study effectively demonstrates that there is definitive evidence that peanut does not readily distribute in the environment and is also readily abatable from surfaces. Dr. Greenhawt expresses the opinion that, although not specifically studied, this implies that peanut products eaten in an environment such as an airline cabin likely could be detected on a non-wiped tray table, common surface, seat, and on cabin floors but that there is a very low likelihood that there is any distribution of peanut dust through the air ("as a cloud that can be inhaled") and that the particles rapidly fall to the surface below the area of consumption.

What is the evidence supporting a threshold level for ingestion above which a reaction is likely?

Dr. Greenhawt defines a threshold level for ingestion above which a reaction is likely as "the level of exposure to an allergen that would be tolerated by a susceptible individual before an allergic reaction would be triggered". Dr. Greenhawt explains that scientific data for determining a threshold level is difficult to obtain and somewhat controversial, at least from an ethical point of view, as the process to obtain the data would essentially put people with allergies at risk of exposure.

The concern that minimal risk is too much risk puts threshold-based research in limbo. For example, a 2013 survey of over 3000 respondents conducted by the U.S. food allergy advocacy group, Food Allergy Research and Education, noted that if a product was labelled "may contain" or made on shared equipment (in referring to their child's particular food allergen), 82.9 percent were uncertain whether they would purchase the product for their child, even if they were told that it was absolutely safe, while 93 percent of respondents said that they simply would not purchase the product, even if the symptoms from ingestion would be mild.

Dr. Greenhawt expresses the opinion that harmless exposure to trace levels of allergy likely occurs frequently, demonstrating that some patients tolerate some low level exposure to their offending allergen. Studies conducted in the U.S. and the U.K. between 2001 and 2010, concluded that there is actually a wide range of potential contamination in commercial products, ranging from 3 to 15,000 parts per million in certain products, which are minute quantities.

Some research has been done to explore potential threshold limits for peanut, tree nut and sesame seed allergens. Dr. Greenhawt refers to two 2013 European studies that were conducted to determine what is known as an "eliciting dose" that could help establish a general population threshold to these allergens. In the first study, test subjects were given doses of peanut (1.56mg), cashew (7.41mg), and hazelnut (0.29mg) to ingest. Subjective symptoms were seen at 0.14mg, 0.32mg, and 0.05mg of ingested allergen, demonstrating the difficulty in defining true versus perceived symptoms. The second study noted an eliciting dose of 1.95 mg for peanut allergen. A third European study conducted in 2015, noted symptoms of peanut allergy at 2.8 mg of ingested peanut allergen, and 8.5 mg of ingested hazelnut, yet subjective symptoms were seen at much lower levels. Dr. Greenhawt concludes that this implies that there is likely a threshold dose for exposure to peanut, nut and sesame seeds allergens, but that other factors, such as environmental or subjective symptoms, will play a role in how this is determined.

Dr. Greenhawt also examined how threshold data could be compared with data from the aforementioned abatement and environmental exposure experiments to verify whether detectable limits after cleaning would pose a risk. Dr. Greenhawt found that residual amounts recovered from laminate/wood surfaces after cleaning using detergent (or a similar agent), or contact with saliva after someone ate peanut would be highly unlikely to provoke objective symptoms in the vast majority of patients.

Section III: Flying with peanut/tree nut/sesame seed allergy, and risk mitigation strategies

There is a lack of data indicating the precise incidence/prevalence rate of in-flight food allergies to peanuts, nuts and sesame seeds, attributable to the fact that most reported incidents are almost exclusively subjective and self/proxy-reported, as opposed to documented medical events. Validating these reports is challenging, given the high rate of purportedly inhalational or contact-based incidents, which are controversial in nature based on a lack of data supporting these routes as likely to trigger an allergic reaction.

One study, based on data from the U.S. National Registry of Peanut and Tree Nut Allergy, and conducted in 1999, looked at in-flight allergic reactions to peanut and noted that approximately 10 of 14 individuals reported an in-flight allergic reaction occurring after at least 25 passengers on their flights had been distributed peanuts as a snack. Two additional passengers attributed their reaction to residual fumes from peanut served on an earlier flight, and follow-up case studies revealed an increase in reported incidents related to inhalational exposure.

Dr. Greenhawt notes that no study has been able to support the theory that peanut allergen containing dust is either aerosolized or poses a danger to the allergic individual who breathes the air. Dr. Greenhawt further notes that there are no direct nasal or oral inhalation provocation studies that have been performed that would indicate that nasopharyngeal or oropharyngeal mucosal exposure can trigger an allergic reaction. Research in this area is limited, and a push in 1999 to potentially ban peanut service on commercial aircraft in the United States of America was met with resistance when the U.S. Congress adopted legislation that prevented government funding to assist carriers in providing accommodation to peanut-allergic passengers. The U.S. Congress specified that there would be no funding for research into in-flight allergic reactions until a peer-reviewed, scientific study demonstrated that circulating peanut allergen was detectable and caused harm to allergic persons.

In 2011, the U.S. Department of Transportation reiterated that it would not re-address this law nor involve itself in "the peanut/airline issue", in response to a resurgence of public interest in creating a formal airline policy when funding for the Federal Aviation Administration was being renewed.

Characteristics of reported in-flight reactions

Dr. Greenhawt notes that there are 4 studies of in-flight reactions to peanuts, nuts and sesame seeds, all of which used similar self-reported methodology to obtain the data. The studies cover 749 in-flight reactions, the most recent of which included Canadian, European, Australian, and Asian-reported events in addition to U.S. cases. Each of the 4 studies reported many similarities in terms of peanut-related incidents, events linked to allergen inhalation, a high rate of events resulting in symptoms that would meet the criteria for anaphylaxis, poor utilization of epinephrine in order to treat the reaction, and low involvement of the onboard flight crew in terms of the provision by them of treatment assistance and notifying them that a reaction has occurred. Of note is that 1/3 of the cases reported symptoms consistent with anaphylaxis yet only 10-15 percent of cases received epinephrine as treatment.

Risk mitigation and passenger accommodation

The most recent of the 4 studies, conducted in 2013 and carried out by a team of physicians and academics led by Dr. Greenhawt, examined risk factors associated with allergic reactions and the mitigation measures that may have been taken to help prevent them. Over 3,276 respondents with allergies to peanuts, nuts and sesame seeds from 11 countries participated in this study, some of whom had travelled by air but did not have a reaction. The correlation between passengers who had reactions to those who did not revealed that some passengers requested accommodation measures, including:

Requesting a buffer zone (the extent of the buffer zone was not formally defined)
Requesting an announcement that passengers not eat peanut/tree nut-containing foods
Requesting a peanut/tree nut-free meal
Wiping their tray table
Bringing their own food from home
Avoiding use of airline-provided pillows and blankets.

The study was survey-based and self-reporting, such that despite careful statistical adjustments, it remains unclear whether the lower rate of reactions among some passengers is directly attributable to the above-noted requested accommodation measures. Dr. Greenhawt explained that the study's authors were very careful to denote that the associations noted were between the report of a specific accommodation request/behaviour and the report of not having an in-flight reaction, such that there was no way to verify that: a) the accommodation was actually granted or b) that the accommodation, if granted, influenced the outcome against the low statistical probability that an in-flight reaction may occur. According to Dr. Greenhawt, outside of this study, no other study of accommodation or risk mitigation strategies exists.

Worldwide, few air carriers have adopted policies that provide accommodation for passengers with allergies to peanuts, nuts and sesame seeds. For the few carriers that offer accommodation, there have been no studies as to efficacy of the accommodation. Some airlines have voluntarily decided not to distribute peanut or tree nut-containing items in flight, but this practice has varied over the past 15 years or so. According to Dr. Greenhawt, many airlines have elected to avoid outright restriction, and instead will make a request to passengers to not consume peanut/tree nut-containing foods in addition to not distributing these items, but only upon passenger request. Some carriers will also institute buffer zones, but this accommodation is not mandated outside of Canada and is variably used voluntarily by a few U.S. carriers upon request. In discussing the level of evidence supporting a buffer zone, Dr. Greenhawt notes that it is unclear what the level of evidence was to support this risk-mitigation strategy ordered by the Agency in the Allergy Decision, as well as what the rate and severity of in-flight peanut reactions were prior to the order. Dr. Greenhawt further notes that since the Agency's decision, there have not been any studies to determine the efficacy of a buffer zone, its outcomes, or whether there has been a reduction in the number of allergic events.

Section IV: Airflow circulation in a pressurized cabin and the evidence supporting the potential efficacy of allergen restriction and buffer zones

The quality and flow of air in a pressurized aircraft cabin

Aircraft cabins are pressurized to account for high altitudes, which lowers the amount of available oxygen for passengers. Cabin air is re-circulated, and usually mixed with fresh air that is drawn into the moving aircraft from the turbine intake of the engine, with eventual dispersion into the ventilation system. From the ventilation system, the flow pattern of air is cross-sectional and bisects the width of the fuselage in a side-to-side pattern, with laminar (undisrupted, smooth) and downward directional flow from both sides of the aircraft as air enters above the seating row and over the seated passenger's head. Air will then exit via floor vents, which preserves a deliberate cross-sectionalized air delivery pattern and limits longitudinal airflow from the front to the back of the cabin. This airflow pattern limits the spread of airborne infectious particles.

HEPA filters, which are used on most commercial aircraft, remove up to 99.9 percent of particles at a lower limit of 0.3 microns in size. Most commercial aircraft use about 50 percent re-circulated air, which is passed through the HEPA filter. There are no Canadian ventilation standards for commercial aircraft or requirements pertaining to HEPA filters.

Passenger movement on board the aircraft has been shown to change the way air flows within the pressurized cabin environment. Bodies moving in the aisle will help create downward airflow behind the person (similar to a boat wake) behind the torso, which augments the direction of the downward flow emanating from the ventilation system naturally. A study on potential infectious disease dissemination on aircraft (more specifically, in response to the 2003 outbreak of Severe Acute Respiratory Disease (SARS) among passengers on a flight from China), indicated that human movement up and down the aisle (e.g., mimicking normal crew activity) has significant local effects that somewhat prevent side to side movement of respiratory particles. Such movement may increase longitudinal movement of particles, in that movement itself is thought to increase infection risk between 1-2 percent, which when exploring potential routes of dissemination for SARS on aircraft was not felt to be significant. Dr. Greenhawt comments that this particular study is noteworthy in that it is the closest approximation of a model to how other potentially aerosolized agents, (including food allergens such as peanuts, nuts and sesame seeds), may react in a pressurized aircraft cabin environment. However, Dr. Greenhawt emphasizes that food allergens would be much larger in size such that it is unclear how appropriate this model would be to draw conclusions on the aerosolization of peanut, nut and sesame seed allergens.

Allergen buffer zones as a specific risk mitigation strategy

Buffer zones are generally used to minimize the risk of exposure to airborne peanut (or other allergen) particles around an artificially constructed area. Typically, this consists of 1 to 3 rows forward and behind the allergic passenger's seat, and can span both sides and aisles of the aircraft around a specific row.

Dr. Greenhawt expresses the opinion that there are some potential weaknesses with a buffer zone policy. Firstly, there is a lack of data proving conclusively that peanut, tree nut, and sesame seed allergens can become airborne; secondly, buffer zones remain a scientifically untested hypothesis – an accommodation without empirical evidence. Dr. Greenhawt states that conceptually there are multiple common sense and scientific challenges that could be raised, suggesting that this strategy is most likely a measure of comfort and psychological accommodation rather than a physiologic one. There has been no study demonstrating that a buffer zone has been shown to have clinical efficacy, or if other abatement techniques (e.g. not distributing allergen containing products, cleaning of personal areas, or multiple permutations of several strategies, etc.) would have comparative efficacy. There is also no data suggesting the optimal placement or size of a buffer zone to achieve maximum affect.

Airflow considerations suggest that airflow occurs on a cross-sectional arc and not longitudinal within the cabin, and flows from the overhead above the level of the passenger’s head outward to the middle of the aisle and then downward towards the feet such that it is unclear what the extent of exposure could be, if any at all. Even if a buffer zone were created, theoretically a passenger would likely still have to walk through the buffer zone into unprotected areas (e.g. to use the bathroom, or to enplane/deplane), which would effectively defeat the purpose of partial isolation.

To achieve maximum effectiveness, a static buffer zone would have to be set up daily and remain in use, in the exact same location, for each and every flight of that aircraft. Over the course of a day’s flights and cabin cleaning cycles, it is possible that this practice would create a sterile environment for this protected zone. However, Dr. Greenhawt notes that it is unclear if this is actually done or if the zoned-off seats move to where the passenger wanting the accommodation is seated such that it is unclear which approach would be more effective. According to Dr. Greenhawt, there are no published studies describing optimal buffer zone placement, which could potentially differ given the variety of aircraft in use.

An additional consideration is the effectiveness of different air carrier cleaning practices, as there could be either an additive or a detrimental effect between the level of surface cleaning over any other accommodation. Even with the establishment of a buffer zone, if an unprotected area is contaminated with trace amounts of peanut, tree nut or sesames seed particles, it is conceivable that a passenger walking through the contaminated area could accidentally come into contact with a contaminated surface (e.g. touching a washroom door handle, or a seat/armrest) and introduce the contaminant to the buffer zone, therefore defeating its purpose.

Dr. Greenhawt concludes that it is “hard to make an accurate determination of the medical necessity, conceptual feasibility, and technical efficacy of a buffer zone or Air Canada’s buffer zone requirement”. Dr. Greenhawt recommends that the buffer zone requirement imposed on Air Canada be better tested for efficacy, and if proven efficacious, that it then be tested for optimization in terms of where on an aircraft it would work best, how many seats/rows are necessary, and what other strategies may help optimize the buffer zone’s efficacy. As it currently stands, given the dynamics of cabin airflow, the lack of evidence that peanut aerosolizes, and the evidence that surface wiping as abatement is highly effective, Dr. Greenhawt strongly encourages that the requirement be re-evaluated for evidence of necessity, "which given present evidence would be highly questionable”.

Finally, Dr. Greenhawt recommends that if the buffer zone does not provide any level of protection, the requirement imposed on Air Canada should be abandoned so as to not provide any misleading sense of security.

Recommendations for optimal management and treatment of an in-flight allergic reaction

Allergic reactions are serious medical events that must be dealt with promptly and appropriately. There is some evidence to suggest that reactions are often poorly recognized and may frequently be inappropriately treated (e.g. epinephrine not administered or administered after significant delay). In-flight allergic reactions are more problematic, as access to proper treatment and medication is not as readily available. Although air carriers in Canada and the United States of America are required by law to have onboard medical kits, flight crews are not trained emergency medical technicians and there is not always a passenger on board who is a qualified physician and who can treat a potential problem. It is therefore crucial that flight crew be able to properly identify the signs and symptoms of an allergic reaction and be able to quickly provide appropriate treatment for the reaction, particularly given that, whatever margin of error exists on the ground, is further reduced while in flight.

It is equally vital that the passenger with an allergy be prepared to recognize and self-manage a reaction that may occur and the crew to be able to help recognize, assist, and facilitate treatment. It is also highly recommended that passengers provide advance notification (i.e. prior to boarding the aircraft) to the in-flight staff of their allergies.

Even with these measures in place, there is evidence to suggest that crew involvement during an allergic reaction is minimal and that passengers having reactions do not readily notify the crew that a reaction is occurring.

Administration of epinephrine as a means of treatment, even as symptoms consistent with anaphylaxis persist, also appears underutilized. In Dr. Greenhawt's 2013 study, it was noted that nearly all of the passengers reporting reactions had their own source of self-injectable epinephrine, and modelled the factors associated with epinephrine use, such as reporting cardiovascular symptoms and having a personal epinephrine source available. It was also noted across the aforementioned 4 studies, that the majority of reactions (including severe reactions) were treated with diphenhydramine (antihistamine) as a first line agent, and epinephrine was commonly not administered despite it being available in multiple capacities (from the passenger and in the aircraft medical kit).

Special concerns for air travellers experiencing an allergic reaction

Studies have indicated that the reduction of available oxygen at cruising altitudes results in passengers experiencing mild relative hypoxia (deficiency in the amount of oxygen reaching the tissues) as the fraction of inhaled oxygen decreases from 21 percent to 15-17 percent. The effects will matter more to older passengers and passengers who have certain types of disease.

Passengers with allergies will likely experience minimal susceptibility to the effects of the reduced oxygen, however, it is unclear what the effect of the reduced oxygen may be during an allergic reaction with respiratory symptoms. There are no studies that can prove or disprove the risk; however, Dr. Greenhawt notes that aircraft carry supplemental oxygen, which could be useful in those situations.

In-flight medical emergencies, while challenging to address, are essentially managed the same way as emergencies on the ground. The passenger having an allergic reaction should be assessed as quickly as possible to determine the extent of symptoms, unless the passenger is able to describe their symptoms. Some allergy advocacy groups argue that epinephrine should be administered right away, while other groups suggest that this may not be necessary, given that not all allergic reactions result in anaphylaxis or require epinephrine. Dr. Greenhawt is of the opinion that epinephrine should be given as a first line agent for any respiratory or cardiovascular symptoms, or if there is evidence of the involvement of two or more organ systems.

Passengers are usually recommended to seek further medical attention once a flight has landed, as symptoms resulting from an allergic reaction can recur up to 36 hours after a reaction although less than 20 percent of persons having an allergic reaction require a second dose of epinephrine.

There are various practices for prescribing epinephrine for persons with allergies. Some health care providers will not prescribe self-injectable epinephrine if there is no history of a prior severe reaction. Whether or not epinephrine is prescribed could also be based on which type of health care provider makes this decision - an allergist, a general practitioner, or a physician extender. In other cases, some patients with mild food allergies will be prescribed an epinephrine auto-injector with instructions to administer a dose even if there is suspicion of possible allergen ingestion and in the absence of or only minimal symptoms.

Further consideration should be given to how passengers with allergies to peanuts, nuts and sesame seeds prepare for air travel. Some may be instructed by their health care practitioner to carry their prescribed medication on board, while others may not be instructed to do so, or may forget. Further still, some passengers may receive additional information, such as how to clean their personal seating area in preparation for their flight, request peanut distribution restrictions, buffer zones, nut-free flights etc. Other passengers may not receive any additional information.

Dr. Greenhawt states that the following would be generally recommended as reasonable steps for the treatment of in-flight reactions:

Prompt notification of cabin crew that a reaction is occurring, irrespective of severity.
Notification of the captain, after a crew member has assessed the situation, given the potential for the need to divert the aircraft.
Identification of any medical personnel on board to assist/direct treatment and/or activation of ground-based telemedicine so that the onboard medical kit can be immediately accessed.
Administration of 1:1000 strength epinephrine (0.15mg for passengers up to 25kg, and 0.3mg for passengers >25kg) for any cardiovascular or respiratory symptom, vomiting, diffuse hives, or symptoms in two or more organ systems simultaneously. Epinephrine can be administered every 5-15 minutes if symptoms do not respond. If two doses of epinephrine have been administered, the captain should very strongly consider diversion so that the passenger can be taken for monitoring and possible further treatment at a hospital. A medical team should meet the aircraft upon arrival.
For less severe symptoms, antihistamine should be administered (approximately 1mg/kg, which can be rounded to 12.5mg for up to 10kg, 25mg for up to 25kg, 37.5mg for 25-35kg, and 50mg for 35kg or higher). If symptoms are not responding, or additional symptoms emerge, administer epinephrine as described above.
In conjunction with any onboard or ground-based medical consultation, if the reaction appears to have resolved, the captain may elect to continue to the scheduled destination and not divert the aircraft. The passenger should be continuously observed for progression of the reaction for the remainder of the flight, and then assessed by airport medical services on arrival.
The cabin of that aircraft should be thoroughly cleaned before the next flight and the medical kit re-stocked before the next flight.

Regardless of service restrictions or seating policies, Dr. Greenhawt recommends that cabin crews receive training on how to identify signs of an allergic reaction, and how to both draw/administer epinephrine from an ampule vial as well as use an epinephrine auto-injector. In addition, strong consideration should be given to including epinephrine auto-injectors in onboard medical kits, which may greatly simplify treating a patient.

3.1.2 Recommendations

Dr. Greenhawt makes several key recommendations:

More studies should be conducted to provide evidence of the medical necessity of accommodation measures. Despite an increase of in-flight reactions, there remains no study conducted during flight or at ground level that can substantiate potential particle circulation, and no controlled studies that directly prove that common accommodations (e.g. restriction of service, buffer zones) often provided to food allergic travellers are either efficacious or necessary. Dr. Greenhawt notes that while such accommodations may provide personal comfort to an affected passenger or family, as a matter of enacting policy, more evidence of medical necessity must be demonstrated;
The buffer zone requirement should be empirically tested to demonstrate that there is risk necessitating the establishment of the zone, which would also necessitate that a study be conducted demonstrating that peanut allergens can become airborne and circulate in the aircraft cabin environment;
An empirical examination on the placement and effectiveness of a buffer zone, including the effect of routine passenger/crew movement in and out of the buffer zone, should be conducted. Alternative measures, such as personal abatement (e.g. the use of commercial wipes) should also be examined to see if they are effective, or even superior to a buffer zone;
All Canadian air carriers should implement a training program for their in-flight staff in order that they can recognize the signs and symptoms of a passenger having an allergic reaction. Staff should also be trained in withdrawal and intramuscular injection of epinephrine from an ampoule and the use of an auto-injector (EpiPen®). Auto-injectors should form part of the onboard medical kit; and,
If the Agency continues to require Air Canada to have a buffer zone policy, a national registry of in-flight reactions should be created in order that the incidence and epidemiology of these events can be better understood and passengers involved can be directed to the care of a board-certified allergist for education regarding anaphylaxis management.

3.2 Potential for Human Exposure to Peanut, Tree Nut, and Sesame Seed Allergens in Commercial Aircraft Cabins (National Research Council Canada)

An NRC multi-disciplinary group with expertise in aerospace engineering, indoor air quality, ventilation, environmental health, exposure science, and biology was retained to produce a report on occurrences of anaphylactic and asthmatic reactions on aircraft with more than 30 seats; nut-based allergens and the way they interact in an indoor environment; the interaction of nut-based allergens within the aircraft cabin environment (including onboard environment control systems, air filtration and circulation effectiveness); and knowledge gaps that should be addressed in the future.

In order to reduce redundancy, allergy-related matters already covered in the preceding summary of Dr. Greenhawt's report, including references to identical studies, are not repeated here; rather, the summary of the findings in the NRC report (below) focuses on matters related to air circulation and filtration.

3.2.1 Findings

Aircraft Environmental Control System

An environmental control system (ECS) provides ventilation inside the aircraft cabin and flight deck. This is not only vital to the operation of the aircraft, but also provides comfort for passengers and the crew.

The ECS is typically made up of an outside air supply system, heat exchangers, air cycle machines, filtration (if used) and air delivery systems. Each aircraft is unique, resulting in different airflow patterns for each aircraft, even those having the same make and model. Canadian air carriers must comply with requirements for ECS systems prescribed by the Canadian Aviation Regulations. The requirements ensure that certain operating parameters are met, while maintaining the safety and integrity of the aircraft. Of note is that ECS systems, even on identical makes and models, can be individually adjusted to suit the air carrier's needs.

There is a lack of precise information on aircraft cabin airflow rates. Even with some known variables, there are a number of factors that affect airflow patterns, including the aircraft configuration, the placement of air supply nozzles and air return registers, and even the number of occupants inside the aircraft, which will affect, to some extent, the airflow rates. Although the aircraft cabin air exchange rate can be calculated, the air exchange rate can vary throughout the cabin.

The approach in determining how allergens move and interact through the aircraft cabin environment will be largely influenced by the ECS and distribution of airflow. No publications of air velocity measurements inside an airworthy aircraft could be found, but some articles discussing air velocity measurements in aircraft cabin mock-ups were noted (though this may not be representative of a cabin used in flight). In short, there is a lack of concrete information regarding allergen particle interactions in the aircraft cabin environment.

Classifications of aircraft

Transport Canada's registered airline operator list was used to determine the types of aircraft that are in operation in Canada for inclusion in a review of the types of air filtration systems, including filters, currently in use.

There are over 40 types of aircraft in operation in Canada. For simplification purposes, the ECS designs in these types of aircraft were grouped according to:

Wide-body aircraft;
Narrow-body aircraft;
Regional jet aircraft; and,
Piston powered aircraft.

Wide-body aircraft have twin-aisles and can have 7 or more seats per row. Certain models, such as the Airbus A300, are capable of using 100 percent outside air with no recirculation, while other designs, such as the Boeing 747, use a mixture of outside air and recirculated air in ventilating the aircraft cabin.

Narrow-body aircraft feature a single aisle and usually have 5 or 6 seats per row. The Boeing 737-100/200 models use 100 percent outside air with no recirculation, while the Airbus A320 and other Boeing models in this category use a mixture of outside and recirculated air.

Regional jet aircraft are powered by either a turboprop or a turbofan-style engine. Most of the turboprop-powered aircraft use 100 percent or close to 100 percent outside air.

Piston-powered aircraft, such as the Convair CV-240 aircraft and McDonnell-Douglas DC-3, supply the aircraft cabin with 100 percent outside air. These aircraft are generally smaller and commonly fly at altitudes below 15,000 feet.

In-cabin materials

The types of material in the aircraft environment (e.g. flooring, upholstery, and formed thermoplastics such as tray tables) affect how peanut, nut and sesame allergens are released in the cabin.

Given the complexity and uniqueness of each of these materials and how a passenger may interact with them, once contaminated with nut allergens these materials can promote second-hand exposure and/or serve as reservoirs that can later release allergens; for example, carpeting.

The NRC report recommends that passengers with allergies to peanuts, nuts or sesame seeds ensure that they clean surfaces within their vicinity with which they will come into direct contact (e.g. seat, table tray, arm rest). Cleaning methods also have an impact on effectiveness; commercial household products, such as liquid soap, bar soap and commercial wipes are very effective at removing all traces of peanut particles on surfaces and hands, while hand sanitizers and plain water were less effective. Textured surfaces, such as those found on carpets, upholstery, and seat belt webbing are also more difficult to clean versus hard surfaces, and could in fact act as allergen reservoirs.

Filtration

The NRC report notes that there is a dearth of published information on peanut, nut and sesame seed allergens sampled in the air of indoor environments, let alone in an aircraft cabin environment. The size of a particle will largely determine how it is removed, as size often dictates how a particle will distribute in a given environment. Generally speaking, once a particle becomes airborne in an indoor environment, the most common removal process is via filtration.

The NRC report lists "straining, impaction, interception, diffusion and electrostatic attraction" as the principle methods of filtration. Smaller particles are typically trapped by diffusion, whereas larger particles are trapped either by impaction or interception.

HEPA filters are effective in efficiently trapping particles. Modern aircraft, for the most part, are equipped with a HEPA-grade filter that is rated to remove at least 99.97 percent of particles in the air when located in the ECS "recirculation loop". With this in mind, the NRC report notes that it would be expected that particles containing peanut allergens in the air will be effectively removed through the filtration process "on the first pass". The report also notes however, that some aircraft, such as the Turboprop, are not fitted with any filters, and so this efficiency is lost.

There is a lack of studies regarding the analysis of peanut aeroallergens captured via aircraft filters. The NRC report cites one study, conducted in 1996, in which filter units from the ventilation systems of two commercial aircraft, obtained at the time of their annual replacement, contained measurable amounts of peanut allergens. The study concluded that the most likely source of the allergens found in the filters were from peanuts served in-flight.

Depositing of allergens on surfaces

Deposition is the process in which particles collect or deposit themselves on solid surfaces. Deposition rates largely depend on the size of particles. Airborne particles smaller than 0.1 microns generally behave like gases and do not tend to settle while particles measuring 0.1-1 microns have negligible deposition velocities and those in the range of 1-10 microns have appreciable and constant settling rates. Once a particle has settled, it can be re-introduced into the air. A higher concentration of settled deposited allergens could lead to an increase in the likelihood of topical and/or ingestion-based exposure. It would also be expected that this exposure route would be the most likely route, as surfaces are expected to be the most significant reservoirs for nut allergens following their release within the aircraft cabin. Settled particles in an aircraft environment could be re-introduced into the air through a variety of means, including through passenger movement and air currents.

Unfortunately there are no studies specifically on aeroallergen depositing on indoor surfaces. However, there are studies and data on particle deposition - including velocity, size, and deposition rates - which provide insight on how particles move in an indoor environment. Factors such as air speeds and furnishing in the enclosed environment may play a role. For instance, a study conducted in 2002 found that increasing the mixing speed of four small fans led to an increase in loss of all particle sizes (0.5 and 10 microns). Deposition rates are generally higher in a furnished setting. It is not clear whether this would equally apply to an aircraft cabin environment and the NRC report cautions that it is unclear whether these sorts of particle studies can be applied to peanut, nut or sesame seed allergens.

The NRC report notes that increasing the risk of topical or ingestion-based exposures from a state of deposition to resuspension of allergen particles as a result of walking, aircraft turbulence, and aircraft cleaning may impact inhalation exposures. Depending on cleaning practices in the aircraft cabin, particles could remain in suspension for a longer period of time, especially if the ECS is disengaged.

A 2007 study simulated a commercial aircraft environment in which participants opened 15 bags of unshelled peanuts in small packages and consumed the nuts. Air samples were collected from the areas around the participants eating the peanut product, including from distances 5 to 10 feet away, and from participants sitting next to them. Peanut allergens were undetectable under all simulated scenarios, including a scenario in which participants were allowed to walk on peanut shells and scenarios with decreased room ventilation.

Ventilation

Ventilation refers to the process of exchanging indoor air with outdoor air. According to the NRC report, high air exchange rates would, at least theoretically, lower the concentration of peanut allergens.

A typical air distribution system used in commercial aircraft is called the "mixing system", in which conditioned air is supplied at a high velocity from the ceiling level and exhaust air is extracted at the floor level. Research indicates that this system's ability to control the spreading of airborne particles in the cabin environment has limitations.

In a 2009 study, research on a Boeing 767-300 aircraft showed that particles are significantly controlled by the airflow due to the ventilation system. The study's authors discovered that particles released at points close to the ventilation outlet will cause less air quality problems than those released in the middle region. The study also noted that increasing the ventilation rates may not necessarily benefit the receptor close to the pollutant source. It is not clear whether these sorts of findings would be consistent among all types of aircraft. Finally, a different study was designed to simulate a commercial aircraft environment and reported undetected levels of airborne allergens when air was sampled while peanuts where unshelled and consumed.

3.2.2 Recommendations

A number of knowledge gaps for future work were identified in the NRC report, some of which speak to the limitations of developing any sort of policy regarding peanut, nut and sesame seed allergy accommodations. Addressing these areas may play a role in lowering the incidence rates of in-flight allergic reactions, and also help to improve their outcomes if they do occur.

The most significant identified gap concerns scientific testing in the aircraft environment; specifically, testing for the potential for nut allergens from in-flight foods and meals to become aerosolized, their ability to be transported throughout the cabin, and confirming whether inhalation is a significant exposure route for nut allergens. In the absence of sound, reliable data in the form of scientific testing, what is left is based on self-administered surveys and in-house studies.

With respect to management and risk mitigation measures, the NRC report provides several recommendations, including:

The harmonization of global air carrier or government-level policies addressing allergy accommodations, with a view to immediately implementing effective and cost-efficient strategies;
The creation of a universal database to track in-flight emergencies, the purpose of which would be to promote the safety of passengers with not only peanut, nut and sesame seed allergies, but all allergies;
The creation of an education program for air carrier personnel, specifically the in-flight crew, regarding the severity and risks of allergies and related mitigation measures;
Effective training of the in-flight crew to handle potential allergy-related emergencies, including the administration of injectable epinephrine;
The availability of self-injectable epinephrine (rather than traditional ampoules) in all in-flight emergency medical kits;
The availability of accurate, accessible information regarding air carrier allergy policies; and,
A strategy for physicians to work with their patients in creating an anaphylaxis emergency action plan.

4. Consultations

The Agency consulted with stakeholders in two phases. The first phase consisted of consultations with Canadian air carriers that operate aircraft with 30 seats or more, the purpose of which was to solicit feedback on current risk mitigation measures, complaint statistics, and use of a buffer zone (if applicable).

In the second phase of consultations, the above-noted air carriers, in addition to allergy associations, were asked to respond to 10 questions germane to the reports prepared by Dr. Greenhawt and the NRC and to the Agency's Allergy Decision and were provided an opportunity to share any additional information that they considered relevant.

4.1 Consultations with air carriers

4.1.1 Consultation letter (July 2015)

A consultation letter was sent to the following 17 Canadian air carriers, which carry over 90 percent of domestic passenger traffic:

Air Canada
Air Georgian (an Air Canada Express carrier)
Air North Charter and Training, Ltd.
Air Tindi
Air Transat
Calm Air International, Ltd.
Canadian North
Central Mountain Air
First Air
Flair Airlines
Nolinor Aviation
Pacific Coasta;
Pascan Aviation
Porter Airlines
Sky Regional (an Air Canada Express carrier)
Sunwing Airlines
WestJet

A response rate of 100 percent was achieved.

The Air Transport Association of Canada (ATAC), which represents the interests of members of the Canadian aviation industry, was also provided a copy of the consultation letter, although it did not submit any comments.

Carriers were asked whether they had a policy to accommodate passengers with allergies to peanuts, nuts and sesame seeds. If so, they were asked to provide the following information:

A description of the policy;
The number of passengers accommodated due to their allergies to peanuts, nuts and sesame seeds since the implementation of the policy;
The effectiveness of the accommodation measures provided;
Whether the air carrier operates any aircraft that do not use HEPA filters, and if so, whether a different allergy policy applies to those aircraft and the effectiveness of that policy;
Details regarding any problems the air carrier has experienced in accommodating passengers with allergies to peanuts, nuts and sesame seeds, specifying the nature of the problems; and,
A description of what has been working well in terms of accommodating passengers with allergies to peanuts, nuts and sesame seeds.

Regardless of whether or not the air carrier has an allergy policy, the consultation letter required that they provide information on the number of complaints received by passengers with allergies to peanuts, nuts and sesame seeds. Carriers were also encouraged to provide any other comments or information that may be relevant to the inquiry.

4.1.2 Responses to consultation letter

The carriers' responses to the consultation questions are reflected below.

Air Canada provided its answers on behalf of itself and all of the Air Canada Express carriers (Air Georgian and Sky Regional). References to Air Canada therefore include the Air Canada Express carriers.>

Do air carriers have a policy in place to accommodate passengers with allergies to peanuts, nuts and sesame seeds?

Air Canada, WestJet, Porter, Sunwing, First Air, Air Transat, and Air North all indicate that they have a policy in place to accommodate passengers with allergies to peanuts, nuts and sesame seeds. All but 2 of the carriers offer buffer zone seating; all offer peanut and nut-free meals either in the cabin or within the buffer zone (but do not guarantee that there are no traces of the allergens in the food they serve); and some make general announcements asking passengers to refrain from consuming peanuts, nuts or sesame seeds, while others limit such a request to passengers seated in the buffer zone.

The remaining carriers report that they do not have a policy to accommodate passengers with allergies to peanuts, nuts and sesame seeds. However, despite not having a formal policy, the following carriers provide the accommodation measures described below:

Canadian North: its caterers have been instructed to not provide food products containing peanuts and/or tree nuts and it does not serve foods containing peanuts or nut products;
Central Mountain Air: receives ingredient lists from its caterers for some items and provides ingredient lists to passengers, if requested. It will inform its passengers that its catering has been prepared in a facility with nuts and seeds and that the food may have come into contact with these allergens;
Air Tindi: only provides light snacks on its publicly-available flights and offers snack options that are free of peanuts, nuts and sesame seeds;
Pacific Coastal: flight attendants receive training to assist a passenger having an allergic reaction, which includes the use of their epinephrine auto-injector, and all its onboard food is nut-free;
Nolinor Aviation: sends an e-mail in advance of travel asking passengers to advise of any meal restrictions and provides meals that address these. The carrier also ensures that flight crew are aware of passengers with allergies and advises its staff not to bring on board any snacks that might contain peanuts, nuts or sesame seeds. The carrier also ensures that aircraft are thoroughly cleaned and disinfected prior to departure;
Pascan Aviation: as a small operation, it does not have a flight crew, and its Pascan Express service, which does offer some onboard services, has been temporarily suspended since October 2015; and,
Calm Air: it accommodates passengers who advise of their allergies, but did not describe how it does so.

The number of passengers accommodated due to their allergies to peanuts, nuts and sesame seeds since the implementation of the policy

Most carriers replied that they do not keep statistics on the number of passengers with allergies to peanuts, nuts and sesame seeds who have been accommodated. However, a few carriers were able to provide the following statistics:

Air Canada: Since August 2013, there were 4,965 bookings containing a request for accommodation due to allergies to peanuts or tree nuts. This number does not include passengers who show up with a doctor's note at the time of boarding and who are still accommodated;
Porter Airlines: has received 2,255 requests for accommodation of an allergy to nuts since January 2013, and in this time, .01 percent of passengers requesting accommodation have communicated a concern about their travel experience. Porter has no recorded flight diversions or cabin crew interventions related to a nut allergy;
Air Transat: in 2014 it accommodated approximately 500 passengers with nut-related allergies. It indicated that it does not have a significant number of requests regarding sesame seeds;
WestJet: in 2014, it received 1122 nut-related allergy requests, and 39 seed-related requests; and as of August 2015, it received 658 nut-related allergy requests and 37 seed-related requests.>

The effectiveness of accommodation measures provided to passengers with allergies to peanuts, nuts and sesame seeds.

Air Tindi, Canadian North, Calm Air, Central Mountain Air, First Air, Flair Air, Pacific Coastal and Pascan Aviation offered no information in response to this question.

Air Canada notes that before it moved to a simplified procedure for providing accommodation for allergies, the requirements for medical clearance combined with the fact that many passengers showed up at the last minute to request accommodation without going through the clearance process caused considerable operational challenges. Air Canada believes that its revised policy and procedures provide more than adequate protection required for passengers with allergies to peanuts, nuts and sesame seeds.

WestJet notes that, between January 2014 and July 2015, it received positive comments from 26 guests who had received allergy accommodation and feedback from 10 guests indicating that they encountered issues related to their nut allergy on board their flight.

Porter notes that the Allergy Decision has provided a useful framework for its policies and procedures. The carrier also notes that passenger feedback has been favourable about the briefing provided by the cabin crew to passengers seated in the nut-free buffer zone.

Air North notes that advance notification from a passenger with an allergy is "the best approach" as it ensures that flight crew are aware of the passenger's needs.

Sunwing notes that it has not received any complaints relating to peanut, nut or sesame seed allergies.

Nolinor indicates that it has not experienced any incidents related to allergies and that it appears that the measures that it employs are effective.

Do you have aircraft that do not use HEPA filters, and if so, whether a different allergy policy is applied on those aircraft and the effectiveness of that policy.

WestJet, Porter, Sunwing, and Air Transat report that their aircraft fleets use HEPA filters. Air Canada notes that its own fleet and its Air Canada Rouge fleet use HEPA filters, however, some of its Air Canada Jazz and Air Georgian aircraft are not equipped with HEPA filters. Air North and First Air report that some of their aircraft have HEPA filters.

The remaining carriers report that they do not have HEPA filter-equipped aircraft.

There were no cases where a different allergy policy is applied for aircraft not equipped with a HEPA filter.

Provide details regarding any problems experienced in accommodating passengers with allergies to peanuts, nuts and sesame seeds, specifying the nature of the problems, e.g., size of buffer zone, passengers not providing advance notice, etc.

Central Mountain Air, Air Tindi, Pacific Coastal, Flair Air, Nolinor, Pascan, Calm Air, Sunwing, Air North, and First Air report no incidences or complaints.

Air Canada notes that it received 3 complaints from July 1 to December 31, 2012; 8 complaints in 2013; 6 complaints in 2014; and 5 complaints in the first half of 2015. Air Canada explains that there have been misunderstandings as to the size of the buffer zone, as well as some passengers expecting a general announcement as opposed to the announcement within the buffer zone. Air Canada notes that in one case, a passenger had expected a physical barrier around the buffer zone. Additionally, Air Canada indicates that there were some service level issues (e.g., where a flight attendant was alleged to have omitted to make the announcement to passengers within the buffer zone). Air Canada also reports one incident where a passenger who was accommodated in the buffer zone chose to change seats and a passenger nearby took out a peanut butter sandwich causing the passenger with the allergy to hyperventilate.

Feedback from passengers who mentioned that they received allergy accommodation was positive. WestJet notes that in 2014, there were 3 recorded incidents related to nuts, 3 related to "buy onboard product" (unclear whether these were related to nut or sesame ingredients),16 related to external sources (such as perfumes, eating something from an outside source), and 14 "unknown" allergy-related incidents. In 2015, there was one incident related to "buy onboard product" (unclear whether this were related to nut or sesame ingredients), 11 related to external sources (such as perfumes, eating something from an outside source), and 11 "unknown" allergy-related incidents. WestJet commented that feedback from passengers who mentioned that they received allergy accommodation was positive.

Air Transat reports that in 2014, it received 1 complaint from a passenger with an allergy; in 2015, it received 2 complaints, of which one was from a passenger travelling on a flight with a passenger with a nut allergy, who was upset that he was asked not to consume nuts. Occasionally some passengers object to the food restrictions or buffer zones, and these passengers are moved and/or accommodated as a result. The carrier indicates that its procedures and information are public and its gate and in-flight announcements are well received.

Canadian North notes only 1 complaint to date regarding nuts following which the carrier requested that its caterers no longer provide the product containing the nuts.

According to Air North, passengers will generally be asked to be reseated if they are too close to a peanut or nut-based product, in which case flight attendants will do their best to provide the accommodation.

What has been working well in terms of accommodating passengers with allergies to peanuts, nuts and sesame seeds?

Air Canada indicates that its policy and procedures to accommodate passengers with allergies to peanuts, nuts and sesame seeds provide an adequate protection to these passengers.

WestJet is of the view that the evolution of its allergy policy has allowed it to gain more respect and credibility with allergy associations and communities at large.

4.2 Consultations with allergy associations and air carriers on expert reports

4.2.1 Questionnaire

In November 2015, a consultation letter was sent out to the same air carriers that participated in the first round of consultations, ATAC, and 6 Canadian allergy associations, representing a cross-section of national and regional organizations.

Copies of the expert reports were included with the consultation letter. Stakeholders were asked to comment on the reports, and to answer a set of questions.

As part of its submission, Air Canada provided its answers on behalf of itself and all of the Air Canada Express carriers (Air Georgian and Sky Regional). References to Air Canada therefore include the Air Canada Express carriers.

Additionally, Pascan Aviation notes that, as a small operation, it does not have a flight crew, and its Pascan Express service, which does offer some onboard services, has been temporarily suspended since October 2015. Pascan indicates that due to the nature of its operation, most of the questions asked via the consultation letter do not apply to it.

Responses were received from four allergy associations:

The Canadian Society of Allergy and Clinical Immunology (CSACI);
Allergies Québec;
Food Allergy Canada; and
The Canadian Anaphylaxis Initiative (CAI)

4.2.2 Responses to questionnaire

The following is a summary of the responses as they pertain to the 10 questions included in the consultation letter.

Questions for airlines

1. Given the information contained in the expert reports, do you believe that the mitigation measures described in paragraph 64 of Decision No. 228-AT-A-2001 (the Allergy Decision) are suitable for mitigating the risk of an in-flight allergic reaction to peanuts, tree nuts, and sesame seeds?

Air Tindi, Air Transat, First Air, Calm Air, Flair Air, Central Mountain Air, Porter, WestJet, Sunwing, Canadian North, Nolinor Aviation, Pacific Coastal Airlines, and members of ATAC consider the mitigation measures to be acceptable.

Air Canada expresses the view that given that there is no evidence that peanuts, tree nuts or sesame seeds can aerosolize and that the risk that needs addressing is accidental ingestion or contact causing contamination and accidental ingestion (as documented in the expert reports), a buffer zone, other than the bank of seats in which the passenger with an allergy is sitting, serves no purpose.

2. What constraints, if any, would prevent your organization from accommodating persons with disabilities due to allergies to peanuts, nuts, and sesame seeds with the accommodation measures outlined in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision)? Although this decision was limited to allergies to peanuts and nuts, assume in your response that the accommodation measures would also be provided for persons with a disability due to an allergy to sesame seeds.

Air Canada notes that it is currently providing the accommodation measures outlined in paragraph 64 of the Allergy Decision with respect to peanuts and tree nuts. However, it notes that in the Rosenbaum Decision, the Agency determined that the appropriate accommodation for persons with allergies to sesame seeds and all other foods except peanuts and nuts should be the reseating of persons with allergies (upon request and when possible, having regard to safety considerations) in combination with precautions that persons with severe allergies would be expected to take in their daily lives, such as: bringing their own food, hand sanitizer, and disinfectant wipes to wipe down surrounding surfaces; wearing a mask; and carrying EpiPens®. Air Canada expresses the opinion that anything other than the foregoing is unnecessary.

Air Transat, Calm Air, Canadian North, Nolinor, Aviation, Porter Airlines, Central Mountain Air, and Pacific Coastal Airlines all report that there would be little to no constraints that would prevent it from implementing the accommodation measures reflected in the Allergy Decision.

First Air notes that for a passenger who has any allergy, there are many factors that prevent a guarantee that a buffer zone would eliminate contact with allergens. There are seat configurations within First Air's fleet that would not allow it to create a buffer zone as required. Furthermore, there are situations whereby positional seating is required for weight and balance purposes on the aircraft, medivacs, or even the carriage of prisoners that would also hinder First Air's ability to maintain a buffer zone.

Air Tindi indicates that it would be difficult to guarantee a peanut-free zone on its aircraft, noting that it is not based in a major city with easy access to professional groomers.

Flair Air states that its experience is that caterers are unable to provide a guarantee that they can supply food free from peanuts, nuts or sesame seeds, including trace amounts of food that have potentially been exposed to peanuts, nuts and sesame seeds.

Air North notes that some accommodation issues could occur with last-minute flights, as well as with its fleet of Hawker Siddeley 748 aircraft, which have an open seating configuration. Air North notes that it obtains meals from other air carrier kitchens and cannot guarantee that these dishes will be peanut or nut-free free.

Sunwing Airlines writes that it will make all reasonable efforts to prepare the necessary accommodation measures for passengers with allergies to peanuts, nuts, and sesame seeds. It states that advance notice assists it in making these preparations, but in cases where no prior knowledge is provided, it will act in accordance with its policies to provide a safe environment that also meets the needs of the passenger.

WestJet notes that the primary constraint that it would face in implementing the measures would be in terms of non-compliance from other passengers who fail to follow instructions from the in-flight personnel and the "re-accommodations" that would result in the event of a non-compliant passenger.

3. If you believe the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision) should be modified, please describe in what way.

Air Canada expresses the view that the accommodation measures described in paragraph 64 of the Allergy Decision should be modified to limit the buffer zone to the bank of seats in which the passenger with an allergy to peanuts or tree nuts is sitting.

Pacific Coastal Airlines notes that it would be a good idea to keep permanent buffer zones, specific to each aircraft type.

Air Transat, Central Mountain Air, Calm Air, Canadian North, Nolinor Aviation, WestJet, Porter Airlines and Sunwing Airlines indicate that no modifications would be required to the accommodation measures set out in the Allergy Decision. Air Tindi notes that this question does not apply to northern and remote air services, but does not explain further.

4. Describe any alternative(s) to the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision).

In their responses, Air Tindi, Calm Air, Canadian North, Central Mountain Air, Nolinor Aviation, Porter Airlines, Sunwing, and WestJet did not suggest any alternatives.

Air Canada notes that for persons with allergies to sesame seeds and all other foods except peanuts and nuts, it reseats persons with allergies, upon request and when possible, having regard to safety considerations. Air Canada comments that this reseating is appropriate in light of the precautions that persons with severe allergies would be expected to take in their daily lives, such as: bringing their own food, hand sanitizer, and disinfectant wipes to wipe down surrounding surfaces, wearing a mask, and carrying EpiPens®.

Other carrier responses include:

Air Transat notes that it does not use alternative measures, as it applies the measures described in paragraph 64 of the Allergy Decision. Air Transat also notes that, consistent with Dr. Greenhawt's findings, it encourages passengers with various allergies to bring their own food in order to minimize the risk of allergic reactions;
Pacific Coastal Airlines suggests that there are already awareness campaigns in place with certain restrictions, such as the carriage of liquids and gels on board an aircraft, so it would be logical to have an awareness campaign regarding foods that contain peanuts, nuts and sesame seeds, which would not only educate the public, but also assist air carriers in promoting awareness of the issue;
Air North suggests that, in addition to the accommodation measures described in paragraph 64 of the Allergy Decision, it could advise its staff not to use or consume products that contain nuts, peanuts and sesame seeds;
Pascan Aviation suggests that the Agency develop and promote an awareness campaign geared towards smaller air carriers. In its view, it is difficult to determine and control what a passenger might bring on board the aircraft, as there are no flight attendants on board its flights; and,
First Air writes that it cannot implement measures beyond the mitigation measures outlined in the Allergy Decision. Specifically, it cannot modify its cabins or offer better accommodation; however, it notes that it does seek commissary vendors whose products are peanut-and-nut free, but it cannot guarantee that the ingredients used to prepare such foods have not been in contact with peanuts and nuts.

5. Should specific protocols be mandated for cleaning areas of an aircraft in which a person who has provided advance notice of an allergy to peanuts, tree nuts, or sesame seeds, is to be seated?

Pacific Coastal Airlines, Sunwing, Calm Air, Canadian North, and Air Tindi are unsupportive of specific protocols for cleaning; however, Canadian North indicates that it would permit pre-boarding for a passenger to clean their seat.

Other air carriers provided the following responses:

Air Canada is of the view that Dr. Greenhawt and the NRC concluded that these measures are not necessary, and there is really no scientific basis for wiping down the area where the passenger is sitting as the risk of exposure is accidental ingestion. Air Canada also notes that commercial flights do not receive a full grooming before every flight and most of the flights during "a cycle" receive only cursory grooming. Air Canada expresses the opinion that the wiping of the area with a disinfectant wipe by a passenger is sufficient;
First Air agrees with the research that a proper cleaning should take place, however, given the remoteness of some of its operations, retaining the services of a readily available or reliable cleaning contractor may be difficult;
WestJet notes that it would be challenging to prescribe proactive cleaning requirements for the seating area of passengers who self-identify with having allergies to peanuts, nuts and sesame seeds, and cites the following reasons:
- Schedule irregularities would render any cleaning effort ineffective due to aircraft changes (last minute aircraft "swaps/down or gauging"), misconnections, mechanical issues, etc.;
- Existing inability to guarantee same cleaning standard when connecting to partner air carriers;
- Logistical challenges of arranging aircraft cabin grooming where no such services exist; and,
- Added pressure on tight turnaround times for departing aircraft.
Flair Air expresses the view that cleaning protocols should not be mandated as there may be unpredictable circumstances such as flight disruptions due to weather or mechanical problems that may require a last minute change in aircraft or itinerary, therefore making it difficult to guarantee that an aircraft has been cleaned to the extent necessary to prevent any adverse reactions to foods that may contain, or may have come into contact with, peanuts, tree nuts or sesame seeds;
Air North notes that in some cases, such as on its northern scheduled service routes, it would be unable to provide a grooming service, although cleaning agents could be supplied for the flight attendant to use, if needed, assuming that the product did not freeze. Air North expresses the view that its current cleaning protocol for the other aircraft in its fleet does not pose any "threats" to a passenger with food allergies;
Central Mountain Air indicates that advance notice would allow its flight attendants to wipe down the seats in preparation for a passenger with a severe allergy to peanuts, nuts or sesame seeds;
ATAC states that it does not support specific protocols for cleaning areas of an aircraft. It is concerned that certain cleaning agents may contain ingredients that have dangerous goods shipment requirements or hazardous substance implications preventing transport aboard an aircraft for use in cleaning seat areas;
Nolinor Aviation indicates that it does not agree with the proposal as there are so many operational considerations that would create problems for a specific cleaning protocol to be respected at all times; rather, it favours a more general approach to such a cleaning protocol; and,
Central Mountain Air states that advance notice would allow flight attendants to wipe down seats in preparation for a passenger with a severe allergy to peanuts, nuts or sesame seeds.>

6. Should persons who have provided advance notice of an allergy to peanuts, tree nuts, or sesame seeds be permitted to board an aircraft in advance of other passengers so that they may wipe down their seating area?

Air Tindi, Air Transat, Central Mountain Air, Nolinor Aviation, Air North, Canadian North, First Air, Pacific Coastal Airlines and WestJet are supportive of permitting pre-boarding for passengers who have provided advance notice of an allergy to peanuts, nuts, and sesame seeds.

Other air carriers provided the following responses:

Air Canada is of the view, as noted in its response to the preceding question, that there is no scientific basis for wiping down the area where the passenger is sitting as the risk of a reaction is due to accidental ingestion; however, Air Canada notes that should a passenger with an allergy wish to wipe their seating area, it may in fact be more efficient not to have them board first, as depending on where the passenger is sitting in the aircraft, there is a risk of contamination if the area that was just cleaned is exposed to other passengers boarding after the fact. This would be the case of a passenger with an allergy sitting in an aisle seat;
Calm Air expresses the view that passengers with allergies to peanuts, nuts and sesame seeds who have provided advance notice of their allergy should be permitted to board an aircraft in advance of other passengers so that they may wipe down their seating area. However, it also expresses the view that air carriers should not be responsible or liable for cleaning the seating area;
Flair Air states that passengers should be given the opportunity to pre-board in order to clean their immediate seating area, as long as they are aware that unforeseen circumstances, such as delayed arrivals, may preclude them from doing so. Flair Air also writes that cleaning must not delay the boarding process of other passengers or prevent on-time departures of scheduled flights; in other words, it is only in situations where there are no risks to scheduled operations that cleaning by passengers may be considered; and,
ATAC opposes allowing a passenger the option of bringing their own cleaning product on board the aircraft for the purpose of wiping down their own seating area, as it might inadvertently encourage the transportation of items containing prohibited dangerous goods or hazardous substances on board an aircraft, and could also cause security issues when being processed at security check points.

7. Please describe your views on a national registry system to record in-flight allergic reactions to peanuts, tree nuts, and sesame seeds.

Pacific Coastal Airlines, Sunwing, Air North, Central Mountain Air, First Air, Flair Air, Porter, members of ATAC, and WestJet (in principle), support a national registry system to record in-flight allergic reactions to peanuts, nuts and sesame seeds. First Air notes that further information would be needed to fully understand what such a registry would entail.

Air Canada, Air Transat, Air Tindi, Calm Air, Canadian North, Nolinor Aviation, report that they are not in favour of the national registry system. The following reasons were provided:

Putting a registry in place would be cumbersome without providing any real benefit to persons with allergies;
There is no medical or scientific substantiation to support allergic reactions receiving a different treatment than any other medical condition;
The absence of documented medical incidents caused by an allergic reaction to peanuts, nuts and sesame seeds does not mean that an obligation to document would reveal more incidents;
Cannot see the benefit or need;
The administration of multiple layers of compliance and reporting requirements will become so burdensome that only the very largest air carrier will be left operating in Canada; and,
The responsibility should be on the passenger to advise [the carrier of their allergy] and to take the necessary precautions.

8. Should aircraft with less than 100 passengers carry epinephrine?

Air Canada, Calm Air, Nolinor, Porter, Pacific Coastal Airlines, Flair Air, and ATAC are not in favour of aircraft with less than 100 passengers carrying epinephrine.

First Air, Air Transat, Air North, Canadian North, and WestJet support the proposal.

Air Tindi and Central Mountain Air support the carriage of epinephrine for the smaller aircraft but note that passengers with allergies to peanuts, nuts and sesame seeds should be expected to carry their own epinephrine.

Pascan Aviation notes that given its northern-based services, it is not certain whether epinephrine will remain effective in the extreme cold.

9. Should air carriers carry epinephrine in the form of auto-injectors in addition to, or as an alternative to, vials and syringes?

Air Canada submits that it would be impractical, potentially dangerous and cost-prohibitive to require air carriers to carry epinephrine in the form of auto-injectors in addition to, or as an alternative to, vials and syringes. It maintains that passengers with allergies should be required to carry their epinephrine auto-injectors on their person when they travel.

Air Canada's Chief Medical Officer, Dr. Jim Chung, expresses concerns with such a policy. In his view, although epinephrine auto-injectors can be purchased without a prescription, it is important that they be prescribed by a medical professional who would evaluate the person's other medication or medical needs. An injection of a dose contained in an epinephrine auto-injector by a non-medically trained party could provoke a myocardial infarction in high risk individuals. Diagnosing an anaphylactic reaction requiring epinephrine is difficult for a layperson, and sometimes the appropriate medication for a given allergic reaction could be diphenhydramine (antihistamine) or injectable steroids. Permitting non-medically trained personnel to administer an epinephrine auto-injector may cause harm or aggravate the person's condition. Dr. Chung notes that the US Federal Aviation Administration had similar discussions regarding auto-injectors and flight attendants were neither trained nor willing to administer such medication.

Other air carriers provided the following responses:

Air Transat comments that it carries auto-injectors and syringes and that other air carriers should do the same.
Air Tindi, Canadian North, Air North, Central Mountain Air, First Air, and Nolinor agree with the premise, but note that there would need to be regulatory exceptions (the carriers did not elaborate any further).
Several air carriers, including Calm Air and Pacific Coastal Airlines, are unsupportive of air carriers carrying epinephrine in the form of auto-injectors in addition to, or as an alternative to, vials and syringes. Pacific Coastal Airlines expresses the view that the distance to the nearest suitable airport and the required contents of the first aid kit (which, in its case, does not include syringes) are relevant considerations.
Pascan Aviation notes that if epinephrine is required to be transported on board an aircraft, then the simplest and most effective means of administering the product should be the norm.
Both ATAC and Porter note that if air carriers are mandated to carry epinephrine, then the use of auto-injectors is the safest method for use, given its ease of use and prevention of inadvertent contamination or misuse of syringes. ATAC adds that it is concerned about the security and health issues associated with the availability of syringes on board an aircraft.
WestJet notes that auto-injectors tend to be the most practical and efficient means by which to administer epinephrine to a passenger with a severe allergy; however, the carriage of these on board the aircraft should be voluntary. WestJet expresses the view that vials and syringes should remain the minimum mandatory requirement.

10. Should crew be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods?

In their responses, Air Canada, Air Transat, Flair Air, Air Tindi, Canadian North, Pacific Coastal Airlines, First Air, Porter, WestJet, and members of ATAC note that they already provide training that includes how to recognize an allergic reaction, as well as appropriate treatment methods.

Other air carriers provided the following responses:

Calm Air expresses the view that it does not think that crew should be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods, as they are already being asked to take on too many responsibilities regarding passenger health.
Central Mountain Air agrees that the air crew should be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods.
Air North explains that its flight attendants receive first aid training, which includes first aid for severe allergic reactions. It suggests that a video on what to expect could be useful in order that flight attendants would be able to better recognize an urgent allergic reaction and respond appropriately.
Pascan Aviation notes that if some sort of medical assistance or intervention is required, then proper training on how to recognize and treat a passenger having an allergic reaction should be given; however, as 2 crew members are required in order to operate its aircraft, it would be impossible to conduct an emergency landing (if necessary) and treat a passenger having an allergic reaction at the same time.

Questions for allergy associations

Six allergy associations were invited to participate in the consultations and responses were received from:

The Canadian Society of Allergy and Clinical Immunology (CSACI);
Allergies Québec;
Food Allergy Canada; and,
The Canadian Anaphylaxis Initiative (CAI)

What follows is a summary of the responses to the consultation letter's ten questions.

1. Given the information contained in the expert reports, do you believe that the mitigation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision) are suitable for mitigating the risk of an in-flight allergic reaction to peanuts, tree nuts, and sesame seeds?

Responses to this question were varied; some were supportive of the mitigation measures described in the Allergy Decision (namely, the buffer zone) but recognized them as a starting point towards risk reduction for passengers with allergies to peanuts, nuts and sesame seeds, and some either viewed the measures as inadequate or lacking a scientific basis. The responses include the following views:

Consistent with Dr. Greenhawt's and NRC's reports, CSACI expresses the opinion that it is unlikely that aerosolized food proteins from peanuts, tree nuts, or sesame seeds are contributing to onboard allergic reactions. CSACI also expresses the opinion that the buffer zone described in paragraph 64 of the Allergy Decision would do little to address the mostly likely route of exposure, namely ingestion, and that there is likely little value in restricting the meals of individuals seated in rows in front of and behind a passenger with an allergy;
Allergies Québec expresses the view that the measures described in paragraph 64 of the Allergy Decision are suitable, but merely a starting point. Allergies Québec refers to Dr. Greenhawt's report wherein it is mentioned that a fixed buffer zone may be preferable to a rotating one, and wherein the importance of continuing research on the subject to determine whether the buffer zone is an effective way to reduce the risk of an allergic reaction on board an aircraft is stressed. Nonetheless, Allergies Québec comments that the buffer zone policy provides passengers with allergies with some peace of mind;
Food Allergy Canada expresses the view that given the limited amount of scientific research on the risk of in-flight food-related allergic reactions, and that Dr. Greenhawt and NRC both recommend that additional scientific research be carried out to address this, the mitigation measures in paragraph 64 of the Allergy Decision are only a starting point for reducing the risks for passengers with food allergies;
Food Allergy Canada suggests that there are many factors that would affect the outcome of an individual having a serious allergic reaction on board an aircraft, such that it recommends adding the measures noted below in response to the third question in the consultation letter to the measures set out in the Allergy Decision.
CAI indicates that it does not believe that the mitigation measures in paragraph 64 of the Allergy Decision are adequate, as peanut/nut proteins can be transferred to other surfaces outside of the buffer zone and there is a high risk of accidental contact with the allergen. CAI states that it appreciates the availability of a buffer zone, but that "based on the expert testimonies of Drs. Sussman and Vadas [allergists whose reports were considered in the Allergy Decision] – a buffer zone – alone – does not provide adequate risk reduction". CAI maintains that it is not looking for a peanut/nut-free guarantee on flights, but that it is calling for extra caution, as access to emergency care while travelling in an aircraft 35,000 feet above the ground is a risk for passengers with allergies to peanuts and nuts;
CAI notes that in the Allergy Decision, the Agency found that when advance notice is provided, the appropriate accommodation for passengers with allergies to peanuts or nuts is to be seated in a buffer zone. However, CAI points out that the Agency recognizes that, for operational reasons, it may not always be possible to provide a buffer zone when a passenger has not provided advance notice and in those situations, the carrier is to make its best effort to provide the buffer zone. If it is unable to do so, it is to place the passenger on the next available flight and provide a buffer zone at that time. CAI maintains that in this situation, the decision to travel must remain solely with the passenger with allergies; that is, the passenger may choose to continue on their scheduled flight without the buffer zone, or travel on the next flight that can provide a buffer zone. CAI is of the opinion that boarding must not be prevented due to the inability of the air carrier to implement all aspects of the policy; and,
CAI notes that passengers with allergies who travel infrequently may not be aware of the buffer zone policy, such that further education or promotion of the policy should be considered.

2. If you believe the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 should be modified, please describe in what way.

Responses to this question were varied. They include^{Note 3}:

Food Allergy Canada recommends that, at the request of the passenger, the buffer zone be extended to cover seats across the aisle in certain circumstances, notably in aircraft in which passengers with food allergies are seated closer to other passengers directly across the aisle, than to those directly ahead or behind them.
Allergies Québec recommends that research be conducted on buffer zones, including their effectiveness in reducing the risk of an allergic reaction; whether permanently designated buffer zones should remain sanitized throughout the day; and whether the location of an effective buffer zone could be determined following an analysis of air circulation in the aircraft cabin.
CSACI notes that the main benefit of a buffer zone is likely psychological reassurance for the passenger with an allergy and their family. It expresses the opinion that it is unlikely that the buffer zone actually provides a significant reduction in risk, and that it is reasonable to limit its size to the row of seats in which the passenger with allergies is seated;
CSACI states that a reasonable argument could be made that restricting the foods consumed in the buffer zone would provide a level of comfort to the passenger with an allergy and their family, and may also assist in defusing potential conflict between passengers and/or air carrier staff.

3. Would you suggest an alternative(s) to the accommodation measures outlined in paragraph 64 of Decision No. 228-AT-A-2011? If so, why do you believe the alternative could be effective?

This question generated a lot of feedback. Several allergy associations offered detailed suggestions.

Food Allergy Canada suggests:

Mandatory training for in-flight staff, which would include how to identify signs and symptoms of an allergic reaction; an emergency protocol on treating an allergic reaction; and proper use of an epinephrine auto-injector;
Stock epinephrine auto-injectors in the onboard medical emergency kits of all aircraft, regardless of type or size; ensure that in-flight staff are both authorized and trained to administer an auto-injector;
Provide an in-flight announcement, upon a passenger's request, informing other passengers that there is a passenger on board who has peanut/nut allergies and that passengers are asked to refrain from consuming nut-based products;
Air carriers should have a consistent process that allows individuals with food allergies to inform the air carrier of their allergy upon booking their flight so that their information is captured in the flight details provided to the crew;
Once a passenger with food allergies has self-identified, the air carrier should, upon registering their flight: inform the passenger of the air carrier's allergy policy; remind them to carry their epinephrine auto-injector on their person and bring their own food; and, upon check-in, repeat these reminders;
Air carriers should be required to have written policies and procedures for accommodating passengers with food allergies, and this information should be easily accessible on their websites to enable passengers with food allergies to make informed decisions prior to booking their flight and plan accordingly; and,
Passengers with food allergies should not be denied access to air travel as a result of their food allergy.

Allergies Québec proposes the following:

Written allergy accommodation policies for air carriers should be easily accessible to passengers with allergies to peanuts, nuts and sesame seeds. Air carrier staff should also be familiar with the policies;>
Ensure that flight crews are regularly trained to recognize and react to allergic reactions;>
Ensure epinephrine auto-injectors (rather than syringes and vials) are available in the onboard first aid kits and that flight crews are capable of using the auto-injectors; and,>
Consider standardized forms for storing passenger information, including emergency plans. >

CSACI suggests wiping down the seat, armrests, and tray tables before the passenger with an allergy is seated.

Given that both Dr. Greenhawt and NRC are of the opinion that the most likely route of exposure is ingestion, this would be the most effective measure to decrease the chance of a reaction, particularly if the allergic passenger is a child, as children are prone to inadvertent ingestion.

CAI suggests that air carriers should do the following to reduce the risk of accidental exposure:

work with their caterers to eliminate peanut/nuts from their products or provide some peanut/nut-free food choices;
stop serving peanuts or nuts if there is an allergic passenger on board;
ask passengers to refrain from consuming peanuts/nuts during the flight;
accept an epinephrine auto-injector with a pharmacy sticker or a doctor's note as sufficient identification of a passenger's allergy; and,
introduce simpler ways for passengers to notify the air carrier of allergies at the time of booking.

At the same time, CAI recognizes that there will be some passengers who will not respect the request to refrain from consuming peanuts/nuts during the flight, but that an in-flight announcement would still reduce the risk of exposure. CAI comments that not seating non-compliant passengers in the buffer zone ensures that the zones are effective.

As part of its comments and in response to this question, CAI also included its proposal for an allergy protocol for airlines, which was prepared in 2013, entitled "Risk Reduction for Anaphylactic Passengers^{Note 4}" which states:

"Two Step Policy – to be implemented as soon as possible.

Step 1)

Suspend serving and selling peanuts/nuts/sesame snaps in Business, Executive and Economy Class, when an allergic person makes the request.

Announcement made at departure gate and on board, requesting that passengers do not open or consume any peanuts/nuts during this flight. Passengers would not be asked to refrain from eating products labelled only as 'may contain' peanuts or nuts.

The epinephrine auto-injector (EAI) carried by the anaphylactic passenger (or caregiver), with the pharmacy sticker or a doctor's note is sufficient medical identification.

Allow pre-board in order to speak with In-Charge Flight Attendant and to wipe down seat area. Require flight crew to be trained and authorized to administer an epinephrine auto injector.

Add an 'Allergy Notification' on the Passenger Information List (PIL) to alert staff to expect the allergic passenger.

Flight Booking Notice: "Please be prepared for possible food restrictions on your flight – in support of our anaphylactic passengers."

Step 2)

For passengers allergic to foods other than peanuts/nuts, with 48 hours' notice, the airline will make every effort to come to an agreeable arrangement.

Step 1 & 2)

Flight crew will be trained never to refuse boarding to a passenger solely on the basis of that person's food allergy and anaphylaxis risk."

In addition to the proposed allergy protocol, CAI also provides a rationale for some of its recommendations. With respect to making announcements at the departure gate and on board the aircraft, CAI notes that this would enable passengers to purchase an appropriate snack prior to boarding the aircraft, and is consistent with a recommendation made in an expert report referenced in the Allergy Decision that a general announcement be made to inform all passengers that there is an allergic individual on board. The requirement that the flight crew be trained and authorized to administer an epinephrine auto-injector is supported by the same expert report;

Regarding a flight booking notice advising passengers of possible food restrictions on their flight, CAI advises that this would forewarn passengers, even in advance of travel; and,

With respect to the training of flight crews to never refuse boarding to a passenger solely on the basis of that person's food allergy and anaphylaxis risk, CAI maintains that the effectiveness of a policy will be dependent upon its use by anaphylactic passengers; any fear of being denied boarding as a result of a passenger identifying themselves as being anaphylactic would be a major barrier to fully disclosing their condition in the first place. If an air carrier is unable to comply with the policy for any reason, the decision on whether to board the flight must remain the responsibility of the anaphylactic passenger – boarding should not be prevented because the air carrier cannot implement all aspects of the policy.

4. Should specific protocols be mandated for cleaning areas of an aircraft in which a person who has provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds is to be seated?

There was unanimous support from the allergy associations for specific protocols to be mandated for cleaning areas of an aircraft in which a person who has provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds is to be seated.

CSACI and Food Allergy Canada agree that cleaning protocols should be mandated, noting that specific protocols for cleaning, or simply providing the passenger necessary materials (e.g. wipes) and some time to clean the area, would be advisable. The associations express the view that this would not be a time-consuming procedure, and that it would be limited to the specific seating area in which the passenger with a food allergy would be seated.

Other responses include the following:

Allergies Québec notes that cleaning is a proven way to remove allergens from surfaces and that a specific cleaning protocol should be put in place to ensure adequate cleaning of potentially contaminated surfaces. Sanitary wipes should be accessible to passengers wishing to clean their own seating area; and,
CAI, although in agreement with the premise of mandated cleaning protocols, states that it is not sure how an air carrier would manage this, but if it could be managed, additional cleaning would be a welcome risk reduction measure; moreover, it would be preferable for air carrier staff to clean the area, including washrooms, rather than the passenger with an allergy.

5. Should persons who have provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds be permitted to board an aircraft in advance of other passengers so that they may wipe down their seating area?

There was nearly full support for allowing passengers who have provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds, to be permitted advance boarding so that they may wipe down their seating area. However, CSACI did not support this measure. It expresses the view that the air carrier should decide when, in the boarding sequence, passengers with food allergies should board as the air carrier would determine the most efficient way to do so while allowing time for the passenger to wipe down their seat area. It also notes that likely most of the affected passengers would be smaller children, whose families have already been provided with pre-boarding access.

Allergy associations in support of permitting passengers who have provided advance notice of an allergy to pre-board to wipe down their seating area made the following comments:

Allergies Québec expresses the view that the practice may help to reduce the amount of allergens on board the aircraft and should not be limited to peanut and nut-based allergens as any passenger at risk of severe anaphylaxis should be permitted the opportunity to sanitize their immediate area;
Food Allergy Canada refers to Dr. Greenhawt's report that notes that studies have shown that effective cleaning with readily available cleaning supplies, such as commercial wipes or cleaning agents, was successful in removing peanut residue from surfaces. In addition, Food Allergy Canada recommends that passengers with food allergies check seat cushions, seat back tables and storage areas for potential allergens; and,
CAI notes that pre-boarding provides the opportunity for a passenger with a food allergy to perform a visual inspection for any stray nuts that may have fallen on the floor, seat, or in the seat pocket. CAI further notes that it is not always possible to effectively manage these precautions once general boarding has commenced and the aisles are filling up with passengers.

6. Please describe your views on a national registry system to record in-flight allergic reactions to peanuts, tree nuts, and sesame seeds.

The allergy associations express unanimous support for a national registry system to record in-flight allergic reactions to peanuts, tree nuts, and sesame seeds.

Responses included the following:

Food Allergy Canada expresses the view that a national registry would benefit air carriers, the Agency, medical professionals and allergy associations, as it would provide insight into the incidence, causes, and treatment of in-flight allergic reactions. In addition, a national registry could be used to identify any gaps in education, training, and allergy management - for both travellers with food allergies and the airline industry – as well as provide insight into future policy-making and training requirements;
Allergies Québec expresses support for a national registry as a valuable tool and notes that having information on the number of in-flight allergic reactions, their source and the medical steps taken to address them would be consistent with Dr. Greenhawt's recommendations. In its view, a national registry could help identify any shortcomings of the current system, inform policy development, and address the needs of passengers with food allergies and industry alike;
CSACI comments that there is a lack of data regarding in-flight allergic reactions and expresses the opinion that a national registry would help bolster the science in this area, including to help assess whether a significant risk of reactions actually exists, and also to measure the effectiveness of mitigation measures;
CAI expresses the concern that the scope and content of a national registry would need to be discussed in order to ensure that the cause and allergen would be noted. CAI also suggests that passengers participating in the registry need to feel comfortable with disclosing their personal information, "as passengers with anaphylaxis are often treated unkindly and with contempt by airline personnel – as though they are a bother or worse. They are often not believed and treated as though they are overreacting."; and,
CAI recommends that it be mandatory for flight crews to report all instances where they are approached for assistance for any actual or perceived anaphylactic reaction. In addition, it recommends that passengers be allowed to provide their information directly to the registry, and not through a third party (e.g. air carrier).

7. Should epinephrine be available on aircraft carrying less than 100 passengers?

The allergy associations all express the view that epinephrine should be available on aircraft carrying less than 100 passengers and most indicate that delays in administering epinephrine could lead to further serious consequences.

Responses included the following:

CSACI notes that, "epinephrine is the treatment of choice for a significant allergic reaction." CSACI also recommends that all individuals at risk for anaphylaxis carry an epinephrine auto-injector on their person, at all times, including while travelling in an aircraft;
Allergies Québec notes that epinephrine is the only treatment for a severe allergic reaction, and that all air carriers should carry an auto-injector on board. Allergies Québec expresses the opinion that an auto-injector is preferable over traditional vials and syringes, as the latter requires medical intervention. Finally, Allergies Québec suggests that if an epinephrine auto-injector is available on board an aircraft, it would be wise to ensure that the crew is aware of any legal issues and to understand its responsibilities;
CAI expresses the view that epinephrine auto-injectors are soon going to be required by law to be carried on U.S. aircrafts and Canada should also follow suit; and,
Food Allergy Canada states that all aircraft, regardless of passenger size, should carry epinephrine on board, preferably in the form of an auto-injector, as studies have shown that when food allergic reactions have resulted in fatalities, the lack of, delay, and underuse of epinephrine has been noted as a key contributing factor in the outcome.

8. Should air carriers carry epinephrine in the form of auto-injectors rather than vials and syringes?

All the allergy associations express support for air carriers carrying epinephrine in the form of auto-injectors rather than vials and syringes.

Responses included the following:

CSACI and Food Allergy Canada note that epinephrine auto-injectors are easier to use than vials and syringes; generally speaking, auto-injectors are meant to be used by non-medical professionals, which would be beneficial on board an aircraft as flights may not always have a physician on board to provide assistance;
Allergies Québec emphasizes that timing in an emergency is crucial, such that an auto-injector is much more accessible than a syringe and vial; moreover, an auto-injector can be used by a person with no prior medical training, whereas a traditional syringe and vial method requires medical training and/or knowledge;
CAI notes that time is important, and the extra time required to draw up and administer the epinephrine injection is a delay that may increase the risk of worsening reactions, especially if the flight crew needs to call MedAire or some other medical assistance service to obtain instructions for administering a dosage of epinephrine from a vial. CAI also notes that many passengers who are not health care professionals have had training in epinephrine auto-injector use, and that auto-injectors are designed with simplicity in mind, so that even a child can administer a dosage; and,
CSACI notes that auto-injectors eliminate the guesswork and risk of epinephrine dosing errors.

9. Should crew be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods?

The allergy associations all express support for providing training to flight crews on how to recognize signs of an allergic reaction, as well as appropriate treatment methods.

Responses included the following:

CSACI notes that teachers, early childhood care workers, coaches, and many other professions offer training in the use of epinephrine auto-injectors. CSACI also refers to NRC's report wherein it is noted that Air Canada and WestJet flight crews are already trained in first aid treatment, including how to deal with allergic reactions, such that training on the use of auto-injectors could be added to the existing training modules.
Allergies Québec expresses the opinion that staff training is essential. Basic training could include the following elements:
- Strategies and best practices for effectively communicating with passengers with food allergies;
- Identifying symptoms of a severe allergic reaction;
- Prevention strategies;
- Understanding cross-contamination; and,
- Emergency use of an epinephrine auto-injector.
Allergies Québec maintains that there is a shared responsibility between parties, in that not only air carrier staff must be able to respond to the needs of passengers with food allergies - particularly when an allergic reaction is occurring - but that passengers with food allergies must equally ensure that they have properly prepared for their trip in advance of travel.
CAI points out that anaphylaxis training is part of every comprehensive CPR and automated external defibrillator first aid training course, and that the training was one of the recommendations in an expert report referenced in the Allergy Decision.
Food Allergy Canada recommends that training should include how to identify signs and symptoms of an allergic reaction; emergency protocol on treating an allergic reaction (as outlined by the guidelines provided by CSACI); and training on how to use an epinephrine auto-injector.

10. Should the websites of air carriers provide more comprehensive information on allergies to peanuts, tree nuts, and sesame seeds (e.g. how to request accommodation, passenger's rights, passenger's obligations, etc.)?

All the allergy associations agree that having more comprehensive information on allergies to peanuts, tree nuts, and sesame seeds on an air carrier's website is a positive idea for allergic passengers.

Responses include the following:

CAI comments that it would be helpful if the information provided on air carrier websites could also be downloaded as PDF documents that could be printed by the passenger to be used as a reference while they travel;
CAI also suggests that a message be set up on air carrier websites alerting passengers to possible food restrictions on flights, for example, "Please be prepared for possible food restrictions on your flight – in support of our anaphylactic passengers," as people may be more cooperative if they are provided with advance notice; and,
Allergies Québec notes that, although passengers with food allergies are already accustomed to preparing beforehand, and that air travel is no different, useful, current information on air carrier websites would be a welcome tool to help equip allergic passengers.

The general consensus is that having accurate, complete, and consistent information in advance of travel will allow passengers with allergies to make informed choices when booking flights and, at the same time, help ensure that what is expected of an air carrier, and of a passenger with an allergy, is set out in a transparent, consistent and easily accessible format.

5. Analysis and findings

The information obtained from the consultations with air carriers and allergy associations and the expert reports prepared by Dr. Greenhawt and NRC is analysed below in terms of the following 2 key issues:

The risk of anaphylaxis due to inhalation, dermal contact with and/or ingestion of peanut, nut and sesame seed allergens while on board aircraft with 30 or more passenger seats; and,
The effectiveness of current risk-mitigation measures, as outlined in the Allergy Decision.

5.1 Risk of anaphylaxis

5.1.1 Risk due to inhalation

Dr. Greenhawt notes that although inhalation is commonly believed to be a route of exposure, there is no data to support this. On the contrary, Dr. Greenhawt emphasizes that the data that does exist consistently shows that peanut allergens do not aerosolize. Moreover, Dr. Greenhawt points out that there have been no oral or inhalation provocation studies to support the theory that nasopharyngeal or oropharyngeal mucosal exposure can trigger an allergic reaction. For its part, NRC indicates that allergic reactions from unnoticed ingestion are being incorrectly attributed to inhalation, including ingestion as a result of touching a surface on which the allergen has settled and then unknowingly ingesting the allergen.

Both expert reports cite findings from scientific studies that examined measurements of airborne concentrations of peanut protein in the environment and note that none of the results provided proof that peanut allergens can aerosolize. Moreover, even if these allergens could aerosolize, as discussed below, aircraft circulation and filtration systems are such that they do not circulate in the aircraft cabin.

As noted by NRC and Dr. Greenhawt, almost all large Canadian air carriers operate newer generation aircraft that use HEPA filters and a combination of fresh and re-circulated air. Studies show that the use of a HEPA filter is an effective means of reducing the level of particles circulating in the aircraft cabin environment. Typical HEPA filters have at least a 99.97 percent removal efficiency for particles of 0.3 microns which, as noted in the Allergy Decision, is the benchmark used in efficiency ratings because it approximates the most difficult particle size for a filter to capture. The NRC report notes that, considering the very high filtration efficiencies of HEPA filters used in aircraft, it is expected that particles containing peanut allergens in the air (should they exist) will be effectively removed through the filtration process on "the first pass".

With respect to smaller Canadian air carriers that tend to operate aircraft that do not have HEPA filters, these same aircraft generally supply 100 percent fresh air into the aircraft cabin. Additionally, although some of the aircraft are not equipped with filters, the same air exchange principles described above apply. Moreover, as noted by Dr. Greenhawt, HEPA filters on aircraft are not mandated in Canada but regardless of the size of the aircraft and the type of filtration system used, no studies have demonstrated that peanut, nut and sesame seed allergens actually circulate in an enclosed environment, such as an aircraft cabin.

The NRC report refers to nine studies that collected data from air carriers, airports and medical assistance companies in order to characterize the nature of in-flight emergencies. Overall incidence rates for allergic reactions were low and even lower for those attributed to peanuts, nuts and sesame seeds. Additionally, medical emergencies associated with allergic reactions represented a small fraction of all in-flight emergencies.

In terms of the risk of anaphylaxis due to inhalation, the evidence from both expert reports is that peanut, nut and sesame seed-based allergens do not aerosolize and do not readily circulate in the aircraft cabin environment, such that this risk is likely to be immaterial, if it exists at all.

5.1.2 Risk due to dermal contact

In terms of the risk of anaphylaxis related to dermal contact with peanut, nut or sesame seed allergens, Dr. Greenhawt's report indicates that there is minimal risk of anything more than a local irritation reaction from casual skin contact with the allergen. Dr. Greenahwt's report references a 2004 study in which peanut butter was smeared on the skin of participants. The study found that none of the participants demonstrated any systemic allergic reaction to skin contact (or inhalation contact) and the authors of the study concluded that casual environmental contact with peanut butter was highly unlikely to cause generalized reaction of any symptoms, "debunking that such exposures are a potential danger in a public venue".

5.1.3 Risk due to accidental ingestion

Both expert reports provide evidence to support the conclusion that the most likely route of exposure causing an allergic reaction that could lead to anaphylaxis on board an aircraft is via accidental ingestion. Dr. Greenhawt states that the risk of reaction from public exposure is low, except in instances when the product is ingested, and consistent with this, CSACI advocates for mitigation measures that are focused on trying to reduce the possibility of accidental ingestion of peanut, nut and sesame allergens.

5.1.4 Findings

Based on the information provided by the experts, it is clear that there is little to no evidence that there is a risk of anaphylaxis due to inhalation of or dermal contact with peanut, nut or sesame seed allergens; rather, any risk of a serious allergic reaction that might exist would be as a result of accidental ingestion. In terms of the significance of the risk of anaphylaxis due to accidental ingestion, it is noteworthy that none of the air carriers consulted during the inquiry reported any incidents involving anaphylaxis due to allergies to peanuts, nuts or sesame seeds and that Dr. Greenhawt is aware of only one such incident reported to have occurred in the U.K.

In light of the foregoing, the Inquiry Officer finds that there is a limited risk of inflight anaphylactic reactions due to accidental ingestion of peanuts, nuts or sesame seeds but that, given the serious health implications of such a reaction, risk mitigation measures are nonetheless warranted.

5.2 Effectiveness of current risk-mitigation measures

The current risk-mitigation measures as outlined in paragraph 64 of the Allergy Decision are:

When at least 48-hours advance notice is provided to it by persons with disabilities due to their allergy to peanuts or nuts, Air Canada will create a buffer zone as follows for the passenger with a disability due to allergy to peanuts or nuts:
1. for international wide-body aircraft executive class seating, the buffer zone will consist of the pod-seat occupied by the person with a disability due to their allergy to peanuts or nuts;
2. for North American business class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated;
3. for economy class seating, the buffer zone will consist of the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated, and the banks of seats directly in front of and behind the person. In areas where a bulkhead is either directly in front of or behind the bank of seats in which the person with a disability due to their allergy to peanuts or nuts is seated, the buffer zone will consist of the bulkhead, together with the bank of seats in which the person is sitting and the bank of seats directly in front of or behind the person (depending on the location of the bulkhead).
Air Canada will only serve within the buffer zone snacks and meals which do not contain peanuts or nuts as visible or known components, but which may contain traces of peanuts or nuts as a result of cross-contamination.
Air Canada will provide a briefing to passengers within the buffer zone that they must not eat peanuts or nuts, or foods which contain peanuts or nuts.
Air Canada will address situations where a passenger refuses to comply with this requirement by moving the non-obliging passenger or, if necessary due to that passenger's refusal to move, moving the person with the allergy to peanuts or nuts to a seat where the buffer zone can be established.

In addition to the foregoing risk mitigation measures, the Agency recognized that taking the precautions that persons with allergies do in their daily lives, such as carrying and having available wet wipes, sanitizer(s) and Epi-pens as prescribed by the person's physician would complement the accommodation provided by the buffer zone.

While this order was specifically against Air Canada as a result of allergy-related complaints against it, information obtained during the inquiry indicates that 8 other Canadian air carriers covering over 90 percent of the air travel market in Canada (see Appendix A) have implemented many of the above-mentioned mitigation measures.

While most air carriers did not suggest any changes to the mitigation measures outlined in the Allergy Decision, Air Canada recommends that, given that both expert reports noted that there is no evidence that peanuts, nuts or sesame seeds can aerosolize, and that the real risk of anaphylaxis is due to accidental ingestion, the buffer zone accommodation should be modified. More specifically, Air Canada suggests that the buffer zone should be limited to the bank of seats within which the passenger is sitting. This modification was also proposed by the CSACI.

In establishing the buffer zone as the appropriate accommodation for persons with allergies to peanuts and nuts in the Allergy Decision, the Agency relied on information and evidence that was available at the time, including Air Canada's recommendation as to the size of the buffer zone. Dr. Greenhawt’s report, however, emphasizes that the effectiveness of a buffer zone, as described in the Allergy Decision, is an untested accommodation, is not used outside of Canada and the United States of America (with only a handful of U.S. carriers offering it), and more than likely does very little to reduce the risk of having an allergic reaction.

Some allergy associations see value in the use of a buffer zone as a starting point for risk reduction, despite the noted lack of scientific evidence to support its use. In fact, one allergy association supports modifications to the buffer zone, either by extending its size or making it a fixed location on the aircraft. On the other hand, Dr. Greenhawt expresses the view, as does CSACI, that a buffer zone's value can be attributed to it providing some psychological reassurance to passengers with allergies to peanuts, nuts or sesame seeds.

There was general agreement among air carriers and allergy associations that meals and snacks containing peanuts, nuts or sesame seeds should not be served in the buffer zone and passengers in the zone should be required to refrain from eating the allergens or foods containing them.

In terms of a passenger's responsibility for mitigating the risk of experiencing a serious in-flight allergic reaction to peanuts, nuts or sesame seeds, there was general acceptance by the experts, air carriers and allergy associations that persons with such allergies should be expected to take the same precautions that they do in their daily living, including carrying their allergy medication on their person and cleaning their personal space of allergen residues.

Regarding the latter precaution, Dr. Greenhawt's report emphasizes the success of surface wiping as abatement (e.g., wiping a seat or tray table). Evidence that certain wipes and liquid/bar soaps were successful at removing peanut allergen particles smeared on surfaces such as tables, countertops and hands, demonstrates that proper cleaning can be an effective measure to reduce the risk of accidental ingestion and dermal contact with peanut, nut or sesame seed-based allergens.

The NRC and allergy associations also noted the importance of clear communication of allergy policies on air carrier websites in order that passengers can make the necessary arrangements for accommodation and be aware of their own responsibilities (e.g. carrying their medication on their person).

Dr. Greenhawt noted that it is vital that passengers with allergies be prepared to recognize and self-manage a reaction. He also expressed the view that it is crucial that flight crew be able to properly identify the signs and symptoms of an allergic reaction and be able to quickly provide appropriate treatment. Several allergy associations agreed with Dr. Greenhawt's view and recommended that flight crews receive the necessary training.

5.2.1 Findings

Although there was no consensus on a set of measures to mitigate the risk of anaphylaxis due to exposure to peanut, nut and sesame seed allergens during air travel (specifically, accidental ingestion), based on the information obtained from the experts and the consultations (as reflected above), the Inquiry Officer finds that the following mitigation measures would be the most effective:

a buffer zone, consisting of the row in which the allergic passenger sits or the pod-seat, as applicable;
an announcement to other passengers within the buffer zone that they must refrain from eating peanuts, nuts or sesame seeds or foods containing these;
not serving meals or snacks containing peanuts, nuts or sesame seeds in the buffer zone (recognizing that any food may contain trace amounts of the allergens);
advising passengers with allergies to peanuts, nuts and sesame seeds who provide advance notification of their allergies that they are expected to take the same precautions they take during their daily living, including carrying their allergy medication on their person; wiping down their seat area to remove any allergens; bringing their own food;
abatement, by allowing passengers to wipe down their seating areas;
having policies on air carrier websites in order to inform passengers on how to make arrangements for accommodation and what their responsibilities are; and,
training flight crews on signs and symptoms of an allergic reaction.

Although there was significant support expressed by Dr. Greenhawt and the allergy associations for a requirement to carry epinephrine auto-injectors in onboard medical kits in lieu of, or in addition to vials of the medication, most air carriers objected to this, one noting concerns about their limited shelf-life. The Inquiry Officer is of the view that, in light of the fact that persons with allergies can reasonably be expected to take the same precautions that they do in their daily living in order to protect themselves against the risk of serious allergic reactions - and that arguably the most important precaution that they can take is to have any prescribed medication on their person at all times - there is insufficient justification for mandated epinephrine auto-injectors.

In addition to the recommendation regarding allergy policies on air carrier websites, another communication measure suggested by a few air carriers was awareness campaigns, similar to those that restrict the carriage of liquids and gels, to alert the public to the dangers of bringing peanuts, nuts or sesame seeds on board flights. The Inquiry Officer is of the view that the objective of such an awareness campaign would be met through the announcement to passengers sitting in the buffer zone that require them to refrain from eating peanuts, nuts or sesame seeds. As such, the Inquiry Officer finds that an awareness campaign would not be an effective measure to mitigate against the risk of inflight anaphylactic reactions due to exposure to peanut, nut and sesame seed allergens.

Finally, despite some support expressed for a national registry in order to learn more about serious in-flight allergic reactions, it is apparent that the data could not be relied on as it would be largely drawn from self-reported incidents. As noted by Dr. Greenhawt, people often do not properly recognize the symptoms of a serious allergic reaction and can mistakenly attribute what is, in fact, a reaction due to accidental ingestion, to inhalation of an allergen. As such, the Inquiry Officer finds that, unless and until the reliability of data regarding in-flight allergic reactions due to exposure to peanut, nut and sesame seed allergens can be assured, a national registry would not be an effective measure to mitigate against the risk of an inflight anaphylactic reaction to the allergens.

6. Next steps

As directed by former Minister Raitt, the Agency will provide this report containing its findings to the Minister of Transport.

The findings in this report will be used to inform, as appropriate, future Agency actions in order to address the issue of allergies to peanuts, nuts and sesame seeds in air travel on a systemic basis. These actions could include the development of standards, either regulatory or voluntary performance-based ones, and guidance material ito address the issue on a systemic basis.

Endnotes

Endnote 1

Decision No. 228-AT-A-2011: Applications by Sophia Huyer and Rhonda Nugent, on behalf of her daughter Melanie Nugent, against Air Canada (accessed November 17, 2015).

Return to note 1 referrer

Endnote 2

See: https://www.iata.org/whatwedo/safety/health/Documents/Allergen-sensitive-passenger2010.pdf (accessed December 14, 2015).

Return to note 2 referrer

Endnote 3

CAI combined its response with question #3.

Return to note 3 referrer

Endnote 4

This policy forms part of a 5-point action plan that CAI developed after Motion M-230 was passed in the House of Commons on May 22, 2013. Motion M-230 states "that in the opinion of the House, anaphylaxis is a serious concern for an increasing number of Canadians and the government should take the appropriate measures necessary to ensure these Canadians are able to maintain a high quality of life."

Return to note 4 referrer

Appendix A: Air Carrier Policies Regarding Allergies to Peanuts, Nuts and Sesame Seeds

Notes

*Key international carriers were selected based on the volume of passenger traffic into/out of Canada and in order to achieve some global representation.

** Air Canada also includes carriers operating flights for them such as Air Canada Jazz and Air Canada Rouge.

Domestic Carriers

Air Canada (includes carriers operating flights for Air Canada such as Air Canada Jazz and Air Canada Rouge)
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air Canada

WestJet
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	Yes
Carry EpiPen onboard	Yes
EpiPen will be administered only under supervision of Meds (no guarantee)	Yes
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	Yes
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	WestJet

Air Transat
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	Yes
Onboard announcement	Yes
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air Transat

Porter
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Porter

Sunwing
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	Yes
Onboard announcement	Yes
Carry EpiPen onboard	Yes
EpiPen will be administered only under supervision of Meds (no guarantee)	Yes
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Sunwing

Central Mountain
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Air Tindi
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Flair Airlines
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Nolinor
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy: Carrier will accommodate special meal requests

Pacific Coastal
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Pascan Aviation
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Air North
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air North

Calm Air
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	n/a

Canadian North
24-48 hours notice required	Yes
72 + hours notice required	Yes
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	n/a

First Air
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	Yes
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	n/a

Provincial Airlines
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Provincial Airlines

International Carriers

Air France
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air France

Virgin Atlantic
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	Yes
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Virgin Atlantic

Virgin Blue
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Virgin Blue (No allergy policy posted on website)

Alitalia
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	Yes
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	Yes
Antihistamine tablets onboard	Yes
Staff trained for allergy emergencies	Yes
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Alitalia

Swissair
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Swissair

Aeromexico
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Aeromexico (No allergy policy posted on website)

British Airway
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	British Airway

Air New Zealand
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air New Zealand (No allergy policy posted on website)

Qantas (AU)
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Qantas

TAP Portugal
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Emirates (Dubai)
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Emirates (No allergy policy posted on website)

KLM Royal Dutch
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	KLM Royal Dutch

Cathay Pacific
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes (snacks only)
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Cathay Pacific

Lufthansa German
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	Yes
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Lufthansa Airline

Korean Air
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Korean Air (No allergy policy on website)

Malaysia Airlines
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Malaysia Airlines

Turkish Airlines
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Turkish Airlines

Avianca Airlines (Lacsa)
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy posted on website

Egyptair
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Egyptair (No allergy policy on website)

Aer Lingus
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Aer Lingus (No allergy policy posted on website

Etihad Airways
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Etihad Airways (No allergy policy posted on website)

ANA/All Nippon
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	ANA/All Nippon

Asiana Airlines
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	/ns
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Asiana Airlines

JAL - Japan Airlines
24-48 hours notice required	n/a
72 + hours notice required	Yes
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	Yes
Link to policies	JAL - Japan Airlines

Air Algerie
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Air Algerie Customer must indicate allergy at time of booking

Royal Air Maroc
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Royal Air Maroc

US Carriers - Do Not Fly to Canada

United
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	United

American/US Airlines
24-48 hours notice required	Yes
72 + hours notice required	n/a
Special meals (substantially nut-free)	Yes
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	American Airlines

Delta
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	Yes
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Delta

Virgin America
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Virgin America (No allergy policy on website: Guests encouraged to contact airline)

Jet Blue
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	Yes
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	Yes
Onboard announcement to customer in buffer zone (or seated closed by)	Yes
Equipped with HEPA filters	Yes
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	Yes
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Jet Blue

Alaska Airlines
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/s
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	No allergy policy on website

Hawaiian Airlines
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Hawaiian Airlines (No allergy policy: travellers encouraged to take appropriate medical precautions

Southwest
24-48 hours notice required	n/a
72 + hours notice required	n/a
Special meals (substantially nut-free)	n/a
Onboard announcement	n/a
Carry EpiPen onboard	n/a
EpiPen will be administered only under supervision of Meds (no guarantee)	n/a
Buffer zone	n/a
Onboard announcement to customer in buffer zone (or seated closed by)	n/a
Equipped with HEPA filters	n/a
Pre-board	n/a
Refrain from serving peanut/nut meal or snack onboard (never 100% risk free)	n/a
ECARF certification (Allergy-friendly)	n/a
Antihistamine tablets onboard	n/a
Staff trained for allergy emergencies	n/a
Offer special cleaning (for peanut allergies only)upon request	n/a
Link to policies	Southwest

Date modified:: 2016-06-15

Ministerial Inquiry into Allergies to Peanuts, Nuts and Sesame Seeds in Commercial Air Travel - Report of the Inquiry Officer

Executive summary

Introduction and background

Process

Expert reports

Analysis and findings

1. Introduction and background

1.1 Decision No. 228-AT-A-2011 (Allergy Decision)

2. Environmental scan

2.1 Allergy policies for domestic air carriers

2.2 Requirements in international jurisdictions

2.3 Allergy policies of international air carriers

3. Expert reports

3.1 In-Flight Allergic Reactions to Peanuts, Tree Nut and Seeds: Risk Assessment and Management Strategies (Dr. Matthew Greenhawt, M.D., MBA, MSc.)

3.1.1 Findings

Section I: Immunoglobulin E (IgE) mediated food allergy, anaphylaxis, and asthma classification, types of adverse reactions to foods

Allergic and non-immunologic reaction mediators and pathways

Clinical manifestations of food allergy

Symptoms and severity of an allergic reaction

Prevalence/incidence of and specific risks associated with peanut, tree nut, and sesame seed allergies

Section II: Public exposure to peanuts, tree nuts, and sesame seeds and the risk of reaction from inhalation or contact with allergen

Is there risk from environmental exposure on common surfaces or from inhalation exposure?

What is the risk of environmental distribution of peanut, the efficiency of cleaning to abate such levels; and the biologic relevance of such exposure?

What is the evidence supporting a threshold level for ingestion above which a reaction is likely?

Section III: Flying with peanut/tree nut/sesame seed allergy, and risk mitigation strategies

Characteristics of reported in-flight reactions

Risk mitigation and passenger accommodation

Section IV: Airflow circulation in a pressurized cabin and the evidence supporting the potential efficacy of allergen restriction and buffer zones

The quality and flow of air in a pressurized aircraft cabin

Allergen buffer zones as a specific risk mitigation strategy

Recommendations for optimal management and treatment of an in-flight allergic reaction

Recommended contents of the medical kit

Special concerns for air travellers experiencing an allergic reaction

3.1.2 Recommendations

3.2 Potential for Human Exposure to Peanut, Tree Nut, and Sesame Seed Allergens in Commercial Aircraft Cabins (National Research Council Canada)

3.2.1 Findings

Aircraft Environmental Control System

Classifications of aircraft

In-cabin materials

Filtration

Depositing of allergens on surfaces

Ventilation

3.2.2 Recommendations

4. Consultations

4.1 Consultations with air carriers

4.1.1 Consultation letter (July 2015)

4.1.2 Responses to consultation letter

Do air carriers have a policy in place to accommodate passengers with allergies to peanuts, nuts and sesame seeds?

The number of passengers accommodated due to their allergies to peanuts, nuts and sesame seeds since the implementation of the policy

The effectiveness of accommodation measures provided to passengers with allergies to peanuts, nuts and sesame seeds.

Do you have aircraft that do not use HEPA filters, and if so, whether a different allergy policy is applied on those aircraft and the effectiveness of that policy.

Provide details regarding any problems experienced in accommodating passengers with allergies to peanuts, nuts and sesame seeds, specifying the nature of the problems, e.g., size of buffer zone, passengers not providing advance notice, etc.

What has been working well in terms of accommodating passengers with allergies to peanuts, nuts and sesame seeds?

4.2 Consultations with allergy associations and air carriers on expert reports

4.2.1 Questionnaire

4.2.2 Responses to questionnaire

1. Given the information contained in the expert reports, do you believe that the mitigation measures described in paragraph 64 of Decision No. 228-AT-A-2001 (the Allergy Decision) are suitable for mitigating the risk of an in-flight allergic reaction to peanuts, tree nuts, and sesame seeds?

3. If you believe the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision) should be modified, please describe in what way.

4. Describe any alternative(s) to the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision).

5. Should specific protocols be mandated for cleaning areas of an aircraft in which a person who has provided advance notice of an allergy to peanuts, tree nuts, or sesame seeds, is to be seated?

6. Should persons who have provided advance notice of an allergy to peanuts, tree nuts, or sesame seeds be permitted to board an aircraft in advance of other passengers so that they may wipe down their seating area?

7. Please describe your views on a national registry system to record in-flight allergic reactions to peanuts, tree nuts, and sesame seeds.

8. Should aircraft with less than 100 passengers carry epinephrine?

9. Should air carriers carry epinephrine in the form of auto-injectors in addition to, or as an alternative to, vials and syringes?

10. Should crew be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods?

1. Given the information contained in the expert reports, do you believe that the mitigation measures described in paragraph 64 of Decision No. 228-AT-A-2011 (the Allergy Decision) are suitable for mitigating the risk of an in-flight allergic reaction to peanuts, tree nuts, and sesame seeds?

2. If you believe the accommodation measures described in paragraph 64 of Decision No. 228-AT-A-2011 should be modified, please describe in what way.

3. Would you suggest an alternative(s) to the accommodation measures outlined in paragraph 64 of Decision No. 228-AT-A-2011? If so, why do you believe the alternative could be effective?

4. Should specific protocols be mandated for cleaning areas of an aircraft in which a person who has provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds is to be seated?

5. Should persons who have provided advance notice of an allergy to peanuts, tree nuts, and sesame seeds be permitted to board an aircraft in advance of other passengers so that they may wipe down their seating area?

6. Please describe your views on a national registry system to record in-flight allergic reactions to peanuts, tree nuts, and sesame seeds.

7. Should epinephrine be available on aircraft carrying less than 100 passengers?

8. Should air carriers carry epinephrine in the form of auto-injectors rather than vials and syringes?

9. Should crew be provided training on how to recognize signs of an allergic reaction as well as appropriate treatment methods?

10. Should the websites of air carriers provide more comprehensive information on allergies to peanuts, tree nuts, and sesame seeds (e.g. how to request accommodation, passenger's rights, passenger's obligations, etc.)?

5. Analysis and findings

5.1 Risk of anaphylaxis

5.1.1 Risk due to inhalation

5.1.2 Risk due to dermal contact

5.1.3 Risk due to accidental ingestion